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PRIMARY SOCIAL NETWORK: 
PREDICTORS AND CONSEQUENCES OF 
ENTERING AN ADULT CONGREGATE LIVING FACILITY 



By 
MARY J. BEAR 



A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL 
OF THE UNIVERSITY OF FLORIDA IN 
PARTIAL FULFILLMENT OF THE REQUIREMENTS 
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY 



UNIVERSITY OF FLORIDA 
1986 



Copyright 1986 

by 

Mary J. Bear 



ACKNOWLEDGMENTS 

There are many individuals who have given information, 
encouragement, and guidance toward the completion of this 
dissertation. Primary among them are the author's family 
and friends, her chairman and the members of her doctoral 
committee, the residents and their closest others who 
participated in this study, and the managers of the ACLFs 
who invited her into their facilities. To all of these 
people, sincere thanks are extended. Additionally, the 
author wishes especially to acknowledge her grandparents, 
who instilled in her a sense of love and respect for elderly 
people. 



111 



TABLE OF CONTENTS 

P ag e 

ACKNOWLEDGMENTS iii 

ABSTRACT viii 

CHAPTER 

ONE INTRODUCTION 1 

Caring for the Elderly 1 

The Adult Congregate Living 

Facility 5 

Theoretical Gaps 

The Focal Problem 9 

TWO NETWORK ANALYSIS 12 

Emergence and Development 12 

Morphological Concepts 16 

Interactional Concepts 18 

THREE NETWORK VARIABLES AND ACLF 

RELOCATION 27 

Labeling and Referral 27 

Illness and Illness Behavior 33 

Tie Duration 35 

Relocation to Home 37 

FOUR LITERATURE REVIEW: 

NETWORK VARIABLES AND 

INSTITUTIONALIZATION 40 

FIVE DATA AND METHODS 68 

Sampling and Data Collection 68 

Network Delimitation 75 

Measurement of Dependent Variables ... 78 
Measurement of Independent 

Variables 87 



IV 



CHAPTER £fiS£ 

SIX THE PARTICIPANTS: THE NEW 

RESIDENTS 97 

Presenting Demographic and 

Health Profile 97 

Morphological Network 

Characteristics 100 

Range 101 

Density and Degree 103 

Interactional Network 

Characteristics 105 

Tie Content and Directedness . . 105 

Frequency and Duration Ill 

SEVEN BETWEEN-GROUP NETWORK DIFFERENCES 115 

Differences by Sex 117 

Differences by Race 120 

Socioeconomic Differences 123 

Health-Related Differences 127 

EIGHT THE PROCESS OF INSTITUTIONALIZATION .... 132 

Labeling and Referral 132 

The Situation before the Move .... 137 

Ego's Feelings about the Move .... 143 

NINE NETWORK VARIABLES AS PREDICTORS OF 

ACLF ENTRY 146 

Labeling 148 

Referral 153 

Ego's Presenting Health Status .... 157 

Network Deficient Residents 164 

Deficient Total and Relative 

Networks 165 

Deficient Nonrelative 

Network 167 

TEN THE PARTICIPANTS: THE RESIDENTS SIX 

MONTHS LATER 174 

Place of Residence 174 

Perceived Fit 177 

Ego's Health 179 

Alter 's Response 181 

Interactional Network 

Characteristics 183 



CHAPTER 



Page 



Contact Frequency 183 

Tie Content and Directedness. . . 188 

ELEVEN NETWORK VARIABLES AS PREDICTORS OF 

TIE DURATION AND RETURNING HOME 193 

Returning Home . 194 

Tie Duration 202 

Contact Frequency 204 

Closest Other Contact 

Frequency 216 

Material Links 225 

TWELVE CONCLUSIONS: THEORETICAL AND 

PRACTICAL IMPLICATIONS 233 

Theoretical Implications and 

Directions for Future Research . . . 234 

Entering the ACLF 234 

Tie Duration and Returning 

Home 241 

Practical Implications 244 

Strategies to Improve 

Utilization 245 

Strategies to Improve 

ACLF Caring 249 

EMOTIONAL BONDEDNESS SCALE 255 

SHORT PORTABLE MENTAL STATUS 

QUESTIONNAIRE 257 

C INDEX OF INDEPENDENCE IN ACTIVITIES 

OF DAILY LIVING 259 

D INITIAL QUESTIONNAIRE ADDRESSED 

TO RESIDENT 263 

E INITIAL QUESTIONNAIRE ADDRESSED TO 

RESIDENT'S CLOSEST OTHER 271 

F FOLLOW-UP QUESTIONNAIRE ADDRESSED 

TO RESIDENT 279 

G FOLLOW-UP QUESTIONNAIRE ADDRESSED 

TO RESIDENT'S CLOSEST OTHER 287 



APPENDIX 
A 
B 



VI 



appendix £ase 

H MEANS AND STANDARD DEVIATIONS 
OF THE CHARACTERISTICS OF NEW 
RESIDENT'S NETWORKS 296 

I BETWEEN-GROUP NETWORK DIFFERENCES 300 

J VARIABLE EFFECTS ON THE PROCESS 

OF ACLF ENTRY 314 

K VARIABLE EFFECTS ON RETURNING HOME 

AND TIE DURATION 322 

REFERENCES 335 

BIOGRAPHICAL SKETCH 347 



VII 



Abstract of Dissertation Presented to the Graduate School 
of the University of Florida in Partial Fulfillment of the 
Requirements for the Degree of Doctor of Philosophy 



PRIMARY SOCIAL NETWORK: 
PREDICTORS AND CONSEQUENCES OF 
ENTERING AN ADULT CONGREGATE LIVING FACILITY 

By 

Mary J. Bear 

December 1986 

Chairman: Gordon F. Streib 
Major Department: Sociology 

This is a longitudinal study of the effects of the 
elderly' s networks on (a) the process of ACLF (Adult Congre- 
gate Living Facility) entry, (b) the duration of these 
network ties after ACLF entry, and (c) the likelihood of 
returning home after ACLF entry. Data were collected from 
81 ACLF residents aged 60 and older and their closest other 
via personal interviews within two months of the residents 1 
ACLF entry and then six months later. Sampling was limited 
to ACLFs licensed for up to 50 residents in Orange or 
Seminole County, Florida. Interviews included open- and 
close-ended questions and incorporated standardized measure- 
ment tools. A combination of multiple and logistic regres- 
sion and analysis of descriptive data was done. 

Both network variables and the control, socioeconomic 
status, were demonstrated to affect ACLF entry. The 



vm 



intensity of the elderly' s personal relationships and the 
source paying for their ACLF care explained the differential 
involvement of the elderly' s formal and informal networks in 
ACLF entry. Intensity was directly related to the prob- 
ability of professionals labeling the elderly "out of place" 
in their homes. Having one's care state-financed was di- 
rectly related to both the probability of being profession- 
ally labeled and professionally referred to an ACLF. The 
severity of the elderly 's health at ACLF entry was directly 
related to the density and degree of their networks and the 
intensity of their relationships with their closest others. 

The density of the elderly' s networks had the strongest 
effect on the duration of their ties after ACLF entry. The 
higher the density of the elderly 's networks at ACLF entry, the 
more likely their ties endured. Secondary direct effects were 
also shown for reciprocity, better health, being state-financed, 
white, and having returned home. The intensity of the elderly 's 
ties did not explain tie duration. 

The "problem of return" was not inherent in ACLF entry. 
Being in better health had the greatest effect on returning home. 
However, nonwhites, private payers, and those with lower network 
bondedness were also more likely to return home. 



IX 



CHAPTER ONE 
INTRODUCTION 



Carina for the Elderly 

Modernization has yielded many positive consequences in 
the United States, as can be witnessed in the advances 
demonstrated in health technology, economic technology, 
literacy and mass education, and urbanization. Yet as out- 
lined by Cowgill (1974), each of these outcomes has led to a 
multifaceted scenario of secondary consequences. Primary 
among them, in terms of this dissertation, are (a) the aging 
of our population, (b) the increasing absolute and relative 
cost of health care in our society, and (c) the restruc- 
turing of the American family. 

Both the absolute and relative numbers of the elderly 
have increased phenomenally. At the beginning of this cen- 
tury, persons aged 60 or over represented 1 out of every 16 
persons in this country. They now represent about 1 out of 
every 9, or 11.6% (United States Bureau of the Census, 1984) 
and by the year 2030 will represent over one-fourth of the 
total population (Fowles, 1983) . 

Of even greater significance is the growth of the 
really old, or as Neugarten (1974) calls them the "old-old" 
in our population. While the size of the population 60 and 
over has increased by over seven times since 1900, the 



population 75 and over has experienced an elevenfold in- 
crease and the 85 and older age group has multiplied approx- 
imately 18 times. Currently, about one-fourth of the older 
population is 75 and older, and the proportion is expected 
to increase to over one-third by 2030. As for those 85 and 
older, while they now comprise about 1 out of every 16 older 
persons, by 2030 they are projected to represent 1 out of 
every 11 elderly (Fowles, 1983). 

Significantly, these "old-old" are the elderly who are 
most likely to be limited in their activities and/or con- 
fined to bed due to chronic physical and/or mental condi- 
tions. As reported by Fowles (1983) , the results of the 
1977 National Health Interview Survey indicated that when 
one breaks down the 65 and older age group into categories, 
while 9% of those 65 or older were so limited, the percen- 
tage rose from 5% for persons 65-74 to 12% for persons 75- 
84, and 31% for persons 85 years and older. 

As the elderly in general are more prone to utilize 
health care services than the population at large, it is not 
surprising to note that the shift in our population is among 
the major causes of our rise in health care expenditures. 
However, this is not the sole culprit. Other key factors 
include new medical technologies, inflation, and an increase 
in the absolute numbers in our population. Between 1971 and 
1981 health care spending in the United States more 



than tripled, increasing from $83 billion to $287 billion. 
Moreover, projections place health costs in 1990 at roughly 
$756 billion, which is approximately 12% of our gross na- 
tional product (Freeland and Schendler, 1983) . 

Approximately $24 billion was spent on nursing home 
care alone in 1981 (Freeland and Schendler, 1983) . Once 
again, while the elderly as a group are disproportionately 
high users of nursing homes, in 1977 almost 5% of people 65 
years of age and over were nursing home residents; the 
proportion was more than 20% for people 85 years of age and 
older (National Center for Health Statistics, 1981) . 

Finally, modernization has lead to a restructuring of 
the American family, with families becoming smaller and more 
mobile, and with more women entering the work force. For 
instance, while in 1960 only 34.8% of women were in the work 
force, in 1982 this percentage had risen to 52.1% (United 
States Bureau of the Census, 1984) . 

For the elderly this has meant that their families are 
less available to help meet their needs. A large study of 
the elderly living in the inner city of New York (N = 1,552) 
found that over one-third of the respondents had no living 
children and another 11% had none that met the criterion of 
functionality, i.e., that they had relatives living within 
the confines of the city who were seen or heard from regu- 
larly (Cantor, 1979) . Furthermore, even when children are 
available, as the elderly continue to age, one is 



increasingly faced with the situation whereby a 65-year-old 
"child" is responsible for caring for a 85-year-old parent. 
Cantor did demonstrate that to some degree when their family 
is unavailable the elderly are able and willing to substi- 
tute the services of friends and neighbors to meet their 
needs. However, the size of their personal nonrelative 
network also becomes increasingly restricted with age. In 
this same study the mean number of nonrelated friends re- 
ported was .6 8 and the mean number of neighbors known well 
was only 2.1. 

Concern about the quality of life among the elderly and 
the high cost of institutional care has led to the explora- 
tion of alternatives to nursing home placement. As a part 
of this movement an intermediate continuum of living ar- 
rangements for those who no longer "fit comfortably" in 
private homes, but do not yet demand the level of care pro- 
vided by nursing homes is emerging. Included in this inter- 
mediate range of housing alternatives are such living ar- 
rangements as retirement communities, home sharing, foster 
homes, elder cottages, share-a-homes, and adult residential 
care facilities (Habenstein, Kiefer, and Wang, 1976; Lawton, 
1981; Streib, Folts, and Hilker, 1984). Along with these 
emerging environmental alternatives has come the pursuit of 
an attempt to match the elderly most appropriately with the 
available care alternatives. Thus, placement assessment 



tools have begun to surface (Christ, Visscher, and Bates, 
1985; Kleh, 1977; Sherwood, Morris, and Barnhart, 1978). 

The Adult Congregate Living Facility 
The focus of this dissertation is on one particular 
type of adult residential facility, the adult congregate 
living facility (ACLF) . Adult congregate living facilities 
are group living facilities which provide housing, food 
services, and one or more personal services for their resi- 
dents. Personal services include such services as indi- 
vidual assistance with or supervision of essential activi- 
ties of daily living — such as eating, grooming, dressing, 
and ambulation — and the supervision of self-administered 
medication. 

A key difference between ACLFs and nursing homes is 
that, unlike nursing homes, ACLFs are not required to pro- 
vide professional therapy for their residents. Rather, they 
act in a paraprof essional manner "supervising" self-admin- 
istered medications, arranging medical appointments when 
necessary, and reporting deviations from the resident's 
normal appearance and health to the resident's family, or 
primary health provider. 

Nominal designations of the facilities presenting this 
type of residential care services vary from state to state 
with such alternative titles as homes for adults, board and 
care facilities, and licensed boarding facilities being 



common. Additionally, standardized national licensing cri- 
teria are currently lacking. To date, these variations have 
prevented the compilation of national demographic statistics 
on the ACLF alternative. However, statistics have been 
compiled for Florida, which is the state where this disser- 
tation was done. 

Statistics indicate that the ACLF is far from an insig- 
nificant phenomenon in Florida. As of December 1984, there 
were 1,180 licensed ACLFs in Florida, housing 39,500 resi- 
dent beds (Florida Office of Evaluation and Management 
Review, 1985) . A total of 84 ACLFs exist in the Orange 
County area (District 7) alone (Florida Department of Health 
and Rehabilitative Services, 1985) . Furthermore, there 
appears to be a large number of small operators serving less 
than four residents that are unlicensed, and therefore not 
included in these figures. 

In Florida the average ACLF monthly fee is $545, with a 
range from $116 to $1,625 around the state. Interestingly, 
this is less than half of the cost of a nursing home bed, 
which averages around $1,500 (Florida Office of Evaluation 
and Management Review, 1985). Currently, most of the costs 
are covered privately, as Florida only has designated enough 
resources to finance the expenses of 10% of these beds. 
Financing is accomplished by supplementing the resident's 
SSI payment to total $486, which is then paid to the ACLF 
operator. 



Although ACLF living with its official rules and regu- 
lations and presenting accommodations of group life is gen- 
erally more structured than private living arrangements, the 
ACLF is a relatively open institution. Generally, residents 
can come and go as they please without requiring medical 
permission. Private communication, including receiving and 
sending unopened correspondence, telephone access, and lib- 
eral visiting hours (usually defined as all waking hours) , 
is also unrestricted. Additionally, its lack of medical 
staff may be perceived by the residents as contributing to 
its more "home-like" atmosphere. Certainly its cost savings 
alone make it attractive enough to be considered by those 
not requiring more extensive medical care. 

Theoretical flaps 
Given the continuing need among the elderly for insti- 
tutionalized care and the potential attractiveness of ACLF 
living as an alternative for those elderly who do not re- 
quire the more intensive care of a nursing home or hospital, 
a look at the process by which the elderly come to enter an 
ACLF is both timely and necessary. While a fairly large 
body of literature exists on the process of mental institu- 
tionalization for adults (Brown, Birley, and Wing, 1972; 
Goffman, 1961; Greeley, 1972; Hammer, 1963; Horwitz, 1977; 
Perrucci and Targ, 1982; Scheff, 1966; Vaghn and Leff, 
1976) , the literature that looks at ACLF placement is quite 



limited (Florida Office of Evaluation and Management Review, 
1985) . 

The study of relocation of the elderly, a tangential 
and somewhat more encompassing concept than institutional- 
ization per se, has been extensively studied. Yet, the bulk 
of this literature has focused upon the effects of interin- 
stitution relocation on resident mortality (Aldrich and 
Mendkoff, 1963; Coffman, 1981; Gutman and Herbert, 1976; 
Markus, Bleckner, Blooms, and Downs, 1971). While a smaller 
component of this work does examine the effect of resident 
relocation on the resident's network and/or socialization 
patterns (Borup, 1982; Borup, Gallego, and Haffernan, 1976; 
Wells and MacDonald, 1981) , that which directs itself toward 
the network determinants of this process is much more scarce 
(Allison-Cooke, 1982; Lowenthal-Fiske, 1964; Wan and 
Weissert, 1981; Wells and MacDonald, 1981). 

The process of institutionalization is in effect a type 
of illness behavior. While illness behavior has been 
clearly differentiated from the state of being ill 
(Freidson, 1970; Mechanic, 1978), the variables which act to 
determine illness behavior remain under scrutiny. Both 
cultural and structural determinants have been identified 
along with the interrelationship between beliefs and social 
situations. 



The Focal Problem 

This dissertation focused on social network variables 

as primary structural variables influencing the process of 

ACLF entry. As defined by Hammer, Makiesky-Barrow, and 

Gutwirth (1978:523) , 

An individual's social network consists of his 
or her direct social contacts, the relationships 
among them, and their relationships with others 
who are not directly connected to the focal 
individual. Such links may be thought of as 
the basic building blocks of social structure; 
and their formation, maintenance, and severance 
are universal and fundamental processes. 

In terms of the process of ACLF entry, five key variables 
were of interest: (a) the process by which a new resident 
came to be labeled as "out of place" in his/her former 
environment, (b) the process by which a new resident was 
referred to an ACLF, (c) the diagnosed severity of the new 
resident's health condition at the time of his/her move into 
the ACLF, (d) the effect of the move into the ACLF on the 
resident's network relationships, and (e) the probability of 
the resident's relocation to a private residence after ACLF 
placement. 

Given that the relationship of these variables to the 
process of ACLF placement is virtually unexplored, the re- 
searcher built on the general findings that have emerged in 
terms of the relationship between network variables and 
health care utilization and institutionalization. A review 
of related research and theory indicated that both 



10 

structural and interactional network variables influence the 

process of health care utilization and institutionalization. 

In terms of network structure, density appears to be of 

central importance. In terms of interactional variables, 

the intensity and direction of network relationships are 

emerging as the critical variables. Thus, each of these 

variables were examined in terms of ACLF entry. 

Explored were such questions as 

— What are the characteristics of the resident 
of an ACLF? 

— What are the characteristics of the networks 
of ACLF residents? 

— How did the ACLF resident come to recognize 
that his/her current environmental "fit" is 
problematic? 

— How did the ACLF resident become informed of 
ACLFs? 

— How do the residents and their networks 
react to the ACLF move? 

— What is the differential importance of the 
elderly 's formal and informal networks in the 
entry process? 

— What happens to the new resident's previously 
established ties after ACLF relocation? 

— Once placed in an ACLF, what are the 

resident's chances of remaining there? and, 

— To what degree are these processes influenced 
by network density, degree, and the intensity 
and direction of network relationships? 

Answers to such questions were sought via multiple 

methods. A longitudinal design was used with a six-month 

lag between Time 1 and Time 2 data collection. Both the new 



11 



residents and their closest available other were interviewed 
via a combination of face-to-face and telephone contacts. 
Question formats included open-ended and close-ended ques- 
tions and incorporated standardized measurement tools. 

The theoretical basis for this dissertation is pre- 
sented in the second and third chapters. Chapter Two dis- 
cusses network analysis; its emergence and development and 
key conceptual components are outlined. Chapter Three then 
relates the concepts of network theory to the process by 
which a person comes to enter an adult congregate living 
facility. This relocation process is conceptualized as a 
type of illness behavior. In Chapter Four, the previous 
studies which are pertinent to this research are reviewed. 
The methodological approaches used in this dissertation are 
outlined in Chapter Five. Chapters Six through Nine present 
and analyze the results of the data collected at Time 1, and 
Chapters Ten and Eleven analyze the results of the informa- 
tion collected at Time 2. Finally, a discussion of the 
theoretical and practical implications of this dissertation 
is outlined in Chapter Twelve. 



CHAPTER TWO 
NETWORK ANALYSIS 



Emergence and Development 

Network analysis may be understood as an emerging theo- 
retical framework. Its conceptual focus is on the nature 
and patterns of the "links" between people and the effects 
of these "links" on human behavior. Theoretical reviews of 
network analysis generally claim that its developmental 
movement has been from a metamorphical concept of social 
networks to an approach which has developed a concept of 
increased analytical clarity (Mitchell, 1969; Whitten and 
Wolfe, 1973). Barnes (1954) and Bott (1957) are generally 
credited as being among the first to incorporate a more 
rigorous notion of social networks into their research. 
Both of these studies considered how the characteristics of 
sets of interpersonal links acted independently of personal 
attributes to influence the behavior of network members. 

However, while this analysis is valid in so far as it 
traces the utilization of the second-order construct, social 
networks, it fails in that it does not address the develop- 
ment of the meaning and method that has been associated with 
this abstraction (Berger and Kellner, 1981). Along these 
latter lines it seems justified to preface a review of some 
of the more recent developments in network analysis with a 

12 



13 



brief mentioning of the similarities to network analysis 
foreshadowed in the works of Georg Simmel. 

Simmel's work on social forms is amazingly similar in 
focus to the central interest in network analysis — the pat- 
tern and nature of the social links between people and the 
effect of these links on human behavior. A form is "the 
mutual determination and interaction of the elements of 
association" (in Wolff, 1950:44). In essence, then, 
Simmel's "form" is an analyzable social link between two or 
more individuals with a substance that stands apart from the 
unique characteristics of its component elements. It is a 
structure all of its own, a social structure which acts as 
an independent variable influencing human behavior. Under 
this method of abstraction Simmel proceeded to analyze such 
diverse links between people as conflict, intimacy, acquain- 
tanceship, superordination and its companion, subordination. 
Just as Simmel's work directed him toward analysis of 
the "countless minor syntheses" (in Wolff, 1950:9) of indi- 
viduals in the course of their daily existence, so, too, has 
the work of social network theorists lead them away from 
such analytical units as religion, race, sex, and family. 
Rather than focusing on group delineations or "formal" 
social structures, social network theory focuses on the 
connections between people regardless of whether or not 
these connections fall within or cross these inert 



14 

boundaries. However, it is important to note, as Whitten 
and Wolfe (1973) so aptly point out, this theoretical focus 
does not simply leave for network analysis the social 
residuals, i.e., that which remains after "formal" social 
structures are parceled out for analysis. Rather, "network 
analysis provides the investigator with pathways into the 
heart of social systems whether or not the social systems 
have pronounced, formal, perpetuating structural arrange- 
ments with corporate, exclusive characteristics" (Whitten 
and Wolfe, 1973:719) . 

In addition to being interested in analyzing the nature 
of social forms Simmel also focused on how other social 
variables acted to influence the patterns of human inter- 
action; i.e., he was looking at how social factors influ- 
enced the structure of social networks. An exemplary work 
in this vein is Conflict and the Web of Group 
Affiliations (Simmel, 1955). In this essay, Simmel 
demonstrates the influence of modernity on the process of 
group affiliation. A primary consequence of this process of 
modernization is identified as social differentiation. With 
social differentiation, association becomes based upon com- 
mon purpose rather than propinquity. Our social circles, 
thus, lose their concentric formation and become cross- 
cutting circles; i.e., the structure of our social networks 
changes. Here as in network analysis, Simmel is examining 
how the nature of social links is affected by broader social 



15 



changes. In this case, however, rather than looking at the 
characteristics of a given type of dyadic link, Simmel's 
focus extends to the pattern of links that characterizes an 
individual's social environment. 

Barnes* (1954) and Bott's (1957) observations about the 
consequences of modernity on social networks are remarkably 
similar to those introduced by Simmel. For instance, Barnes 
(1954:44) states, "One of the principal formal differences 
between simple, rural, or small-scale societies as against 
modern, civilized, urban or mass societies is that in the 
former the mesh of the social network is small, in the 
latter it is large." Similarly, Bott (1957:100) remarks, 
"Whereas a family in a small-scale, relatively closed soci- 
ety belongs to a small number of groups each with many 
functions, an urban family exists in a network of many 
separate, unconnected institutions each with a specialized 
function. " 

While Barnes and Bott did not recognize the connections 
of their work to Simmel's, Blau cognizantly draws from 
Simmel's work as he analyzes the effects of social structure 
on patterns of interaction (Blau, 1974; Blau, Blum and 
Schwartz, 1982; Blau, Beeker, and Fitzpatrick, 1984). Like 
Simmel, Blau recognized that patterns of cross-cutting cir- 
cles would affect intergroup relationships in a society. 
In fact, Blau's work, "Intersecting social affiliations and 



16 

intermarriage" (Blau et al., 1984) is an explicit test of 
this theory. Intergroup relations were demonstrated to be a 
direct consequence of cross-cutting circles. Although Blau 
does not relate this phenomenon to one's social network, it 
can be seen how he is in effect describing how broader 
social changes have the independent consequence of affecting 
the pattern of interpersonal affiliations, and, thus, of 
changing social networks. 

Morphological Concepts 
Network analysis can focus on the morphological char- 
acteristics of networks and/or interactional network vari- 
ables. As delineated by Mitchell (1969:12), "the morpho- 
logical characteristics refer to the relationship or pat- 
terning of the links in the network in respect to one an- 
other." They focus on the set of relationships included in 
the network of interest. Included under this category of 
analysis are the following concepts: anchorage, range, 
density, and degree. In contrast, interactional criteria 
focus on the dyadic links that comprise any given network. 
Interactional criteria include content, directedness, dur- 
ability, intensity, and frequency. While interactional 
criteria include qualitative as well as quantitative dimen- 
sions, a network's morphological properties are solely quan- 
tifiable variables. Furthermore, as pointed out by Hammer 
(1981), unlike qualitative variables whose first order 



17 

meaning is culturally and hence situationally bounded, mor- 
phological network properties are "socially neutral" 
(Hammer, 1981:47). Hence, they can be used to compare 
networks across person, place, and time. 

A network's anchor is its point of reference (Mitchell, 
1969) . It is the organizing focus of the network. The 
selection of the anchor, or ego, is usually guided by the 
researcher's interest in explaining the relationship of ego 
and ego's network to their presented behavior. 

Network range simply refers to the size of the net- 
work. If researchers are interested in analyzing network 
range they must be able and willing to identify a bounded 
network. While in theory the concept of social network can 
be extended to describe all of the links between persons in 
a given society (Barnes, 1954) realistically, to be analyz- 
able a network must be delimited. In addition to anchorage, 
other methods of network delineation include content speci- 
fication and the determination of the focal social distance 
between ego and alter. In general, content refers to the 
nature of the interactional link between ego and alter. The 
concept of content is useful in that it gives us another way 
of working with an analyzable portion of the total social 
network. The concept of social distances indicates whether 
the links between ego and alter are direct or indirect. 

Density and degree are different indicators of network 
inter connectedness. Density is a measure of network 



18 



completeness. It is the proportion of the theoretically 
possible direct links that exist in a particular network 
(Barnes, 1969) , and, thus, is a structural measure of net- 
work bondedness. For a network, unlike a group, does not 
demand a coordinating organization among its members "only 
some, not all of the component individuals have social 
relationships with one another" (Bott, 1957:58). 

The concept of degree focuses on the average number of 
people in a network who are connected. It indicates the 
average number of people who are bound together. Hence, 
degree refers to the size of a completed network rather than 
the extent to which a network is completed. 

Controlling for network size, density, and degree are 
directly related: as degree increases, so does network 
density. However, when analyzing networks of disparate 
sizes, if the networks have the same degree, the larger 
network will have a lower density than the smaller network. 
Furthermore, two networks with the same density may differ 
substantially in their number of actualized relations due to 
differences in their total numbers (Barnes, 1969; Neimeijer, 
1973) . 

Interactional Concepts 
In contrast to morphology, which describes network 
attributes, interactional network characteristics delineate 
linkage attributes. Included in this category of analysis 



19 



are the following variables: content, directedness, 
durability, intensity, and frequency. 

While the notion of content is critical in network 
analysis, its meaning is not consistent throughout the lit- 
erature. In general, content may be understood as that 
which determines any given interpersonal link. However, 
from this starting point much confusion exists in the lit- 
erature. Two basic directions can be followed. The first, 
as outlined by Mitchell (1969) , focuses on the normative 
context in which interaction takes place. In this vein, 
links are broadly defined in such categories as kinship, 
friendship, and coworkers. The second direction, which is 
more commonly found in the work of researchers focusing on 
interpersonal communications (Epstein, 1961; Kapferer, 1969; 
Sokolvosky, Cohen, Berger and Geiger, 1978) , analyzes con- 
tent in terms of social exchanges. Here one speaks of links 
in terms of specific behaviors, i.e., visiting and conver- 
sation, advice, medical aid, and loan rendering. Such 
transactional content can be further delineated in terms of 
material and nonmaterial content (Cohen and Rajkowski, 
1982) . 

At issue in these varying approaches to operational- 
ization of the concept, content, appears to be the degree to 
which researchers abstract from given behaviors to a cate- 
gory of behaviors to which a sociological meaning is 



20 

applied. Those that focus solely on content in terms of 
basic exchanges refrain from imposing any meaning to the 
behaviors of actors. In so doing, they avoid what Berger 
and Kellner (1981:40) term the problem of "meaning ade- 
quacy." However, they also avoid any conceptualization of 
exchange relationships. 

This is not to say that an exchange framework invari- 
ably prevents conceptualization of behavior. It is possible 
to begin one's research by identifying these specific inter- 
personal links and then work to give them a more abstract 
sociological interpretation. This is attempted in the work 
of Bott (1957) . While Bott does not specifically address 
the notions of content or of interpersonal exchanges, she 
does speak of varying social distances in kinship relation- 
ships. Four qualitative categories are outlined: intimate 
relatives, effective relatives, noneffective relatives, and 
unfamiliar relatives. Categorization is based upon the 
existence of specific social exchanges in relationships. 
For example, while intimate relatives visited frequently and 
engaged in mutual aid, noneffective relatives shared few 
social exchanges. Only knowledge about such gross facts as 
the relative's name and occupation is necessary. 

Wellman (1981) followed a similar strategy in his fol- 
low-up study on the personal communities of East New 
Yorkers. Extensive data were collected on the nature of the 
links comprising any one interpersonal network tie. "Tie 



21 



types" were then categorized according to contact frequency, 
tie content, and tie intimacy into five nonexclusive cate- 
gories: active, intimate, sociable, routine, and sup- 
portive. Information on personal, phone, and written con- 
tact was obtained, with an active contact being defined as 
at least one contact in the last year. While tie intimacy 
was determined rather loosely by the respondent's definition 
of the link as being "close," extensive information was 
gathered on the type (personal service, material, emotional, 
and informational) and direction (instrumental, dependent, 
and reciprocal) of support. All ties who gave the respon- 
dent at least one type of aid were classified as supportive. 

Those with a normative focus do categorize links in 
terms of patterns of behavior. At risk here is whether the 
sociological interpretation of the behaviors is consistent 
with the meanings the actors themselves impose upon their 
behaviors. Often discussed in this vein is the conceptual- 
ization of friendship. Bott pinpoints this clearly in her 
second edition of Family and Social Network (1971:244): 

The definition of "friend" is an important empirical 
problem. I think it best to start by using the 
definitions of one's informants; in questionnaire 
studies one should also remember that "friend" may 
mean very different things to different people. 

Regardless of the approach taken by network theorists 

to content delineation, there is general agreement that 



22 

persons can be bound by variable numbers of links. As 
introduced by Gluckman (1955) , networks which contain only 
one focus of interaction are called "uniplex" or more sim- 
ply, single-stranded relationships. Similarly/ those which 
contain more than one content are called "multiplex" or many 
stranded relationships. 

Disagreement exists as to the degree to which multi- 
plexity is correlated with the strength of an interpersonal 
relationship. As presented by Kapferer (1969:213) , "Multi- 
plex links are stronger than those of uniplex." Bott, too, 
seems to indirectly agree with this assertation as she finds 
that as the number of links between kin increases, so does 
the strength of their relationship (1957) . This position is 
countered by Granovetter (1973:1361), who contends that 
while in some cases multiplex relations may indeed be 
strong, "ties with only one content or with diffuse content 
may be strong as well." This argument is particularly 
relevant because it is generally agreed that while multi- 
plexity is a common feature of interpersonal links in rural 
societies, modern societies tend to be characterized by 
uniplex interpersonal links (Barnes, 1954; Bott, 1957; 
Simmel, 1955) . 

While content refers to the basis of an interpersonal 
link, directedness indicates whether or not the meaning of 
the tie is shared between the parties of a dyad (Mitchell, 
1969) . If the quality of the relationship varies depending 



23 



upon the direction of the interaction, the tie is asym- 
metric, or one-sided. An instrumental tie is one in which 
the content flows only from ego to alter. A dependent tie 
is one in which the content of the tie flows only from alter 
to ego (Sokolovsky et al., 1978). Conversely, in symmetric 
ties the content between the parties is shared. 

While the concept of tie symmetry is often interchanged 
with that of tie reciprocity, reciprocity has a somewhat 
broader meaning. As defined by Gouldner (1960:164), a 
reciprocal tie is one characterized by a "mutually contin- 
gent exchange of benefits." Thus, a tie is reciprocated as 
long as the content exchanged between A and B is perceived 
as roughly equivalent by both parties. Symmetry, on the 
other hand, only exists when the content exchanged between A 
and B is perceived similarly between both parties. Thus, 
while a symmetric relationship is always reciprocal, a 
reciprocal relationship is not always symmetrical. 

Both reciprocity and symmetry have been proposed to 
affect other interactional qualities of a relationship. As 
early as 1960, Gouldner (1960:164) posited that "reciprocal 
relations stabilize patterns." Similarly, in her discussion 
of social distance, Hammer (1963) suggests that when inti- 
macy is shared between parties, their efforts to maintain 
the relationship will be greater than if intimacy is only 



24 



one-sidedly exchanged. Thus, in both of these cases linkage 
durability was proposed to vary with linkage directedness. 

More recently, Wentowski theorized that the role recip- 
rocity played in relationships was normative, "something 
received requires something returned" (1981:602-603). Re- 
turn services may be either immediate or delayed, with 
delays serving them to build up credit for the giving toward 
services they may require in the future. 

A review of network theory leaves one groping for a 
clear and consistent conceptualization of tie intensity. In 
effect, intensity is a component of content as it is a 
measure of linkage variability. More specifically, inten- 
sity may be understood as an indication of the strength of a 
particular link. Yet from that point one finds much dis- 
agreement as to just what a "strong" or "intense" tie is. 

Epstein (1961) seems to relate Bott's (1957) previously 
discussed notion of social distance to intensity, indicating 
that intense or effective relationships involve a high de- 
gree of interpersonal "closeness" and interactional fre- 
quency. Yet, while his work alerts one to the importance of 
identifying this variable, his operationalization of the 
concept is too vague to be useful. 

In a later work Wheeldon (1969) refines Epstein's no- 
tion of intensity, positing that intense or effective rela- 
tionships are many "stranded" or multiplex. Wheeldon goes 



25 

on to say that effective relationships tend to be confined 
to ego's peers, are likely to persist despite vicissitudes, 
and include the people with whom ego gossips with most 
freedom and intensity, and with reference to the explicit 
formulation of moral norms (1969) . Thus, once again, multi- 
plexity is conceived as a component of intensity. Also 
implicit here are the component elements of intimacy and 
reciprocity. 

In his discussion of intensity, Mitchell (1969:27) also 
emphasizes the dimension of tie reciprocity as a key element 
in relationship intensity: "The intensity of a link refers 
to the degree to which individuals are prepared to honour 
obligations or feel free to exercise the rights implied in 
their links to some other person. " Here it needs to be 
pointed out that both Mitchell (1969) and Gouldner (1960) 
have suggested that obligations to return services can ex- 
tend over long periods of time. Thus, even if at present 
there is infrequent communication between ego and alter, 
upon the surfacing of a need on the part of ego, if obliged, 
alter is likely to respond to that need to reciprocate for 
former services on the part of ego. 

Granovetter 's (1973) more recent conceptualization of 
tie intensity or strength is a good synthesis of preceding 
efforts. "The strength of a tie is a (probably linear) 
combination of the amount of time, the emotional intensity, 
the intimacy (mutual confiding) , and the reciprocal services 



26 



which characterize the tie" (1973:1361). So understood, 
intensity is a multiple-dimensioned abstraction with both 
qualitative and quantitative components. 

The final interactional component mentioned in network 
theory is frequency. While its measurement is probably the 
most straightforward, its meaning is somewhat confusing. 
All relationships marked by frequent contact are not intense 
or strong. As pointed out by Mitchell (1969:29), "Contacts 
with workmates may be both regular and frequent, but the 
influence of these workmates over the behavior of an indi- 
vidual may be less than that of a close kinsman whom he sees 
infrequently and irregularly. ..." Yet, it is recognized 
that some minimal frequency of contact is necessary for 
meaningful inclusion of another in ego's network. Further- 
more, this minimal level of contact is likely to vary from 
one situation to another depending on operating social ex- 
pectations. 

Thus, network analysis needs to take into account both 

the global or morphological properties of networks and the 

properties of the particular dyadic ties or linkages within 

a given network. As noted by Lincoln (1982:4), 

The distinction between properties of dyadic 
ties, evaluated separately, and global 
properties of whole networks is particularly 
important. While networks are built from the 
configurations of ties between pairs of nodes, 
most analysts view the whole, in this case, 
as irreducible to the sum of the parts. 



CHAPTER THREE 
NETWORK VARIABLES AND ACLF RELOCATION 



Labeling and Referral 

Relocation into an ACLF is the outcome of an inter- 
active process. Through interaction with others the behav- 
ior of potential ACLF residents becomes redefined or labeled 
as indicative of a state incongruent with their current 
living situation. This is usually due to a perceived in- 
crease in their dependency as a result of recognized physi- 
cal and/or mental health declines. Whether or not their 
behavior is actually "out of place" is not the critical 
element. Rather, it is the interpretation or imputation of 
a deviant meaning to this illness behavior that is of cen- 
tral importance. 

The initial redefinition or labeling of behavior may be 
imputed by the potential ACLF resident, a key network mem- 
ber, or by a health professional. Furthermore, even acts 
committed outside of the range of others may be self-labeled 
as deviant. Due to the reflexive nature of self (Mead, 
1977) , people are able to engage in interactive dialogues 
with themselves. Either potential or committed acts can be 
compared with internalized general community stereotypes and 
anticipated reactions of potential others. The result may 
or may not be the imputation of deviance to a phenomenon. 

27 



28 



Network variables are likely to be important predictors 
of the source of the initial "problematic" label to the 
potential ACLF resident's behavior. In terms of network 
structure or morphology, network density is of central im- 
portance in determining labeling behavior. As posited by 
Granovetter (1973, 1981) and Horwitz (1977), the degree of 
openness or density in ego's network is directly related to 
the number of different information channels which connect 
to ego. Weak ties link. They facilitate the spread of 
novel information to ego. Thus, an open network is likely 
to be more diverse in its attitudes and knowledge base. 
Hence, an open network is more likely to have the knowledge 
necessary to recognize and label ego's behavior as a prob- 
lem. Alternatively, if ego's network is dense it is less 
likely that network members will recognize ego's condition 
as a "problem." Rather, it is more likely that ego's prob- 
lem will be so labeled by a professional outside of ego's 
personal network. 

The intensity of ego's relationship with network mem- 
bers is the primary interactional variable related to la- 
beling behavior. The existence of intense or strong ties 
implies a positive degree of emotional bondedness, instru- 
mental reciprocity, regularity, and duration in relation- 
ships. This, in turn, is likely to be related to willing- 
ness or sense of obligation to "do for" ego (Gouldner, 1960; 



29 

Horowitz and Shindelman, 1983) and hence to network members 1 
tolerance level for ego's behavior. 

It is possible that either willingness or a sense of 
obligation "to do for" ego will be present if ego shares a 
reciprocal relationship with network members, regardless of 
the intensity of that relationship. As outlined by Gouldner 
(1960:170), "the generalized norm of reciprocity evokes 
obligations towards others on the basis of their past behav- 
ior." The balance of exchanges may be based on material 
and/or nonmaterial links. Additionally, the perception of 
the parties to a relationship that "over the long run" the 
balance of exchanges has been equivalent is also important. 

Thus, if ego's network relationships are intense, 
marked by concern and tolerance, or if alter and ego merely 
have a reciprocated tie, network members are likely to 
attempt to cushion ego's declining physical and/or mental 
state and thus provide for a better balance or fit between 
ego and his/her environment. As network members are busy 
directing energies toward making the situation work, it is 
not as likely that they will be the ones to identify ego's 
"fit" as problematic. A professional is then the most 
likely person to recognize and label ego's state as "prob- 
lematic." Alternatively, in a less intense or asymmetric 
relationship network members are more likely to label ego's 
condition as "problematic" and work toward ego's relocation. 



30 



Once the behavior of the potential ACLF resident is 
defined as "out of place," the tendency exists for his/her 
identity to be redefined as one who is "too sick" to remain 
in his/her current living situation. As pointed out by 
Freidson (1970) in the case of illness behavior, if major 
changes in self-identity and role expectations are to occur, 
the illness must be judged to be serious. Then the meaning 
of the act comes to be associated not with just a behavioral 
pattern of the actor; rather, this behavioral pattern, or 
role, comes to be the dominant role by which the individual 
is identified. Lemert (1951) conceptualizes this transform- 
ation of self as the movement from a primary, or situation- 
ally bound definition of deviance to a state of secondary 
deviance where self-definitions of deviance affect all of 
one's behavior patterns. In effect, the sick role becomes 
the "master status" (Becker, 1963) of the potential ACLF 
resident. 

Both past and future actions of the labeled deviant are 
then interpreted as components of this sick role. Past 
events are retrospectively interpreted to support the attri- 
bution of the new label (Schur, 1971). Future actions are 
anticipated to be deviant — and they are likely to be so. 
The power of suggestion (particularly by those in our imme- 
diate social world) is great. As others come to define 
people, so they tend to define themselves. The prospective 



31 

ACLF resident thus comes to see himself/herself as "out of 
place. " 

The degree to which this phenomenon occurs will be 
influenced by the degree of permanency imputed to the sick 
role assigned to the potential ACLF resident. As outlined 
by Freidson (1970) , diseases can be perceived as acute 
(conditionally legitimate) or chronic (unconditionally le- 
gitimate) . In making this distinction Freidson refined 
Parsons* notion of illness behavior (1968). While Parsons 
believed that the imputation of all types of illness behav- 
ior carried the obligation for the "imputee" to pursue a 
return to a healthy status, Freidson stated that only ill- 
nesses judged to be acute carried this expectation. 

Thus, acute illnesses are conditionally legitimate, 
with the "imputees" being excused from their social obliga- 
tions and given extra privileges as long as they are working 
on returning to healthy behavior. Chronic illnesses are 
reacted and responded to differently. By their very defini- 
tion, chronic illnesses are not deviations which one is 
expected to be able to shake. Rather, they are expected to 
be permanently associated with the "imputee." Social reac- 
tions, thus, are relatively unconditional on self-efforts to 
return to a healthier state. Therefore, while states im- 
puted as chronic do carry future role definitions, acute 
conditions are much more temporary in duration. 



32 

Once illness is recognized, the potential ACLF resi- 
dent's illness behaviors may be organized in a highly vari- 
able manner, even in similarly perceived conditions. As 
Freidson (1970:286) so aptly outlines, "Believing oneself to 
be ill does not in itself lead to the use of medical ser- 
vices." Illness behaviors may be unattended, self-attended, 
or help may be sought from others. 

In our culture, physicians tend to be regarded as the 
primary healers of illness, and hence the ones to be sought 
if one is believed to be suffering from a disease. The 
physician can respond to requests for help by controlling or 
reversing the potential ACLF resident's physical and/or 
mental health decline, thus possibly changing the perception 
of his/her state so it is no longer recognized as being "out 
of place." However, it is also possible that the physi- 
cian's response will not lead to a redefinition of the 
potential ACLF resident's illness behaviors. In this case 
the physician may recommend to ego or members of ego's 
network that ego be relocated from his/her home into another 
environment. It is at this point that the physician may 
refer ego to an ACLF. 

However, it is just as likely that ego or one of the 
members of ego's network will be the one to approach a 
physician requesting the screening examination required to 
allow ego to enter a given ACLF. In this case ego or a key 
network member is already knowledgeable about this option 



33 



and is simply using the professional to legitimize ego's 
relocation. 

Once again, the density of ego's network is theorized 
to be a key determinant of these variable sources of ACLF 
referral. Currently, receiving information concerning re- 
location of the elderly once they are perceived no longer to 
"fit" in their current living situation is relatively prob- 
lematic. While the nursing home option is commonly known, 
other more recent alternatives such as the ACLF are more 
elusive. However, as the density of ego's network is dir- 
ectly related to the number of different information chan- 
nels which connect to ego (Granovetter, 1973, 1981; 
Horwitz, 1977) if ego's network is open, it is much more 
likely that a network member will be knowledgeable about 
ACLF's and hence be able to refer ego to an ACLF for resolu- 
tion of his/her problem. On the other hand, if ego's net- 
work is relatively closed or dense, it is likely that this 
information will be transmitted by a professional rather 
than a network member. 

Illness and Illness Behavior 
While often used interchangeably, the notions of ill- 
ness and illness behavior are conceptually different. In 
our culture, behavior that is perceived to be biologically 
deviant is labeled illness. In other words, illness is that 
phenomenon which deviates from what is judged to be healthy 



34 



or normal acts or attributes for a given individual. Alter- 
natively, illness behavior is the response of a given indi- 
vidual to what is perceived to be a biological deviation. 
While illness behavior is related to illness, other key 
variables affect the response of an individual to any par- 
ticular disorder. Thus, for similar biological deviations 
one might witness very different illness behaviors between 
individuals. This argument is also valid in terms of the 
perception of others to any disorder of ego's. Thus, as was 
discussed, for the same biological disorder the response of 
ego's network members will vary in terms of labeling and 
referral. 

Given this scenario, it is likely that the severity of 
ego's disorder will be highly variable at the time of ACLF 
referral. As network density, intensity, and reciprocity 
influence the referral process, it is also likely that they 
will affect the severity of ego's health at the time of 
referral. This is likely to be a direct positive relation- 
ship. While high network density results in referral delays 
due to a lack of information for problem recognition and 
help seeking, intense or reciprocal network relationships 
delay help seeking due to the willingness of network members 
to "do for" ego. This delay in recognition and referral is 
likely to result in a worsening of ego's condition at the 
time of recognition and referral. 



35 

Furthermore, as discussed by Hammer (1963:244), a dense 
network structure facilitates intranetwork support for mem- 
bers struggling to maintain ego in his/her current living 
situation. In essence, "the effects of the patient's behav- 
ior may be shared, thus creating less pressure for the 
severance of ties." Density also plays a role in the pres- 
sure felt by network members to conform to obligations 
incurred through past exchanges in a relationship. This is 
argued by Bott (1957) as she explains the relationship 
between tie interconnectedness and conjugal role separation. 
"If kin see one another frequently, they are able to put 
consistent, almost collective pressure on a family to keep 
up kinship obligations" (1957:60). However, the ease of 
intranetwork communication will vary with link reachability. 
Two networks with the same density may have different rates 
of communication due to differences in their linkage pat- 
terns. 

Tie Duration 
Upon relocation to an ACLF, the redefinition of ego's 
dependency state is complete. The independence of family 
life is shed. Privacy is greatly diminished and life tends 
to be regimented according to the convenience of others. 
While an ACLF does not fit Goffman's (1961) definition of a 
total institution, the ACLF resident is faced with a shared 
living environment with a set of formalized and informalized 



36 

rules. In their discussion of "Share-a-Homes, " Streib et 
al. (1984) describe this type of living situation as an 
amalgam, something midway between institutional and family 
life. 

To some degree, ego's ACLF residency will become a 
major source of both ego's self-identity and of the way 
he/she is perceived by others. No longer will ego be recog- 
nized as an independent individual, one who can do for 
one's self. As ego's identity changes, so will his/her 
network's expectations for ego's behavior. This can result 
in changes in the balance of exchanges in relationships. 
Ego may no longer be able to contribute his/her fair share 
in the balance of "give and take." 

Ego's network can respond to this situation by either 
abandoning ego or by readjusting their expectations of ego, 
but still maintaining network ties. Both the nature of any 
given network link, and the structure of the network itself 
appear to be central variables in this regard. In terms of 
network interactional variables, intensity and reciprocity 
are most likely to relate to the duration of ties after ego 
is relocated into an ACLF. In both cases the relationship 
is posited as positive and direct. Intense relationships 
have "a lot going for them. " Included are such things as 
time, emotional bondedness, and reciprocated material ex- 
changes. In this case it is likely that the depth and 
breadth of the relationships will compensate for ego's 



37 



identity changes. Alternatively, reciprocal relationships 
do not necessarily involve emotional bondedness or long 
standedness on the part of its members. If ego has not 
obligated network members through past services and/or can 
no longer reciprocate alter' s exchanges, it is likely that 
the relationship will be abandoned. Thus, it is proposed 
that if a uniplex tie becomes symmetric, it is less likely 
to endure. 

The key structural variable affecting tie duration is 
density. Once again, the relationship is posited as posi- 
tive. As outlined by Hammer (1963) and Hammer and Shaffer 
(1975) , there are at least three reasons for this relation- 
ship: (1) The formation of dense networks demands more time 
and energy than the formation of open networks, hence mem- 
bers have "more to lose" if the network is disorganized; 
(2) due to its interconnected structure loss of a member 
will demand complete reorganization on the part of a dense 
network; and (3) density allows for greater intranetwork 
support and pressure for norm enforcement, thus facilitating 
the continuation of ties with ego. 

Relocation to Home 
Once applied, the definition of deviance is partic- 
ularly hard to shake. Hawkins and Tiedeman (1975) identify 
this as the problem of return. Access to conventional roles 
is limited, and all behavior tends to be suspect. In terms 



38 



of the ACLF resident, this implies that once the transition 
from one's home has been completed, there is a low likeli- 
hood of returning. While this is true regardless of whether 
or not ego maintains primary network membership, return is 
predicted to be particularly unlikely if network ties are 
broken. Thus, while network tie maintenance is identified 
as a necessary condition for return, even if ties are main- 
tained ego's return home is still unlikely. 

As previously discussed, tie duration is positively 
related to tie intensity, tie reciprocity, and network den- 
sity. This same relationship holds for the severity of 
ego's health at the time of ACLF relocation. Thus, enduring 
ties are most likely to exist when ego's presenting con- 
dition is less healthy. This implies that under these 
conditions ego's relocation to an ACLF was probably delayed 
until no other alternative was possible for the network. 
Notwithstanding an improvement in ego's condition, relo- 
cation is only likely if network normative pressure is great 
enough to result in the further network behavioral adjust- 
ments necessary for ego's move out of the ACLF. 

Alternatively, while ego's presenting health status is 
likely to be better at the time of ACLF relocation, if 
his/her ties are not intense or reciprocated and ego's 
network is relatively open, the conditions that lead to what 
may be perceived as "premature" placement are not likely to 



39 

be altered during ego's residency. Thus, regardless of the 
nature of ego's network once ego is placed in an ACLF, 
relocation to his/her home or that of a network member is 
unlikely. Rather, if relocation is to occur, it will prob- 
ably be to an institution which provides ego with more 
intensive health care, such as a hospital or nursing home. 

In conclusion, after reviewing the emergence and devel- 
opment of network theory and outlining the key components in 
this framework, network variables were related to the pro- 
cess of ACLF relocation. Tie intensity, tie reciprocity, 
and network density were identified as being centrally im- 
portant in this regard. Their effects on "problem" labeling 
and referral, the severity of ego's presenting condition, 
the duration of ego's ties after ACLF placement, and the 
probability of ego returning to his/her home or the home of 
a network member were outlined. A review of the research 
that has addressed these relationships follows. 



CHAPTER FOUR 
LITERATURE REVIEW: 
NETWORK VARIABLES 
AND INSTITUTIONALIZATION 



A key early study that examined the influence of net- 
work variables on the process of mental institutionali- 
zation is Muriel Hammer's 1963 study, "Influence of Small 
Social Networks as Factors on Hospital Admission. " Sampled 
were 55 young and middle-aged adults admitted to Bellevue 
Psychiatric Hospital. Survey data were obtained from both 
the patient and several of his/her network members, with 
data from the person closest to ego considered as the basic 
source of information. 

Three hypotheses were tested and supported with chi- 
square tests: (1) Patients in critical positions in their 
network are hospitalized more rapidly than those in non- 
critical positions. (2) Patients with nonsymmetrical ties 
are less likely to be given assistance in ways which may 
disturb the functioning of other members of the unit and/or 
to have therapy or hospitalization initiated. (3) Tie sev- 
erance (cessation or sharp diminution of contact) is less 
likely for triangular than linear ties. 

Five key points bear mentioning. First, it appears 
that hospitalization was perceived as a form of help ren- 
dering, a conclusion which may or may not be valid. 



40 



41 



While this may explain why hospitalization was included as 
part of the dependent variable, assistance given prior to 
admission, this inclusion seems inappropriate as these may 
be indicators of two different types of behavior — help ren- 
dering and abandonment of ego. Second, as the notion of tie 
criticalness is used to express the existence of important 
instrumental ties from ego to alter, it is really a measure 
of tie directedness. Thus, there is some evidence that if 
ego has a key instrumental tie with alter, hospitalization 
is likely to be more rapid. Third, while the seriousness of 
ego's health status is not tested, duration can be posited 
to be directly related to seriousness. Furthermore, as 
Hammer's measure of duration was admittedly arbitrary, due 
to the complexity of preadmission symptomatology, serious- 
ness at admission is possibly a more valid and reliable 
variable. Fourth, as used by Hammer, symmetry is a measure 
of mutual emotional bondedness to the degree that the per- 
sons involved in the relationship have no other ties which 
are closer. Thus, it is a lack of mutual emotional bonded- 
ness that limits network help rendering activities. And 
fifth, while Hammer uses the notion of triangular vs. linear 
ties instead of density, their meanings are similar. Thus, 
tie severance was found to be negatively related to tie 
density. 



42 



While Lowenthal-Fiske (1964) did not incorporate care- 
fully defined network characteristics into her study on the 
process of mental hospitalization for the elderly, she did 
look at the differential effects of variations in social 
living arrangements (isolation, living alone, living with a 
spouse or one's children, or living with other relatives) on 
this process. Sampled were 534 elderly San Francisco resi- 
dents admitted to psychiatric wards and 600 nonhospitalized 
elderly San Francisco residents. In terms of the process 
towards hospitalization, data on predisposing factors were 
gathered from the person or persons best informed about the 
patient. Semistructured, open-ended interviews were used, 
with 56% of these interviews taking place in person and 44% 
occurring over the telephone. 

In general, hospitalization was preceded by a long 
period of illness for the patient, during which time a 
variety of prealternatives were attempted. Interestingly, 
the social living arrangements of the patients were shown to 
have a greater influence on the course of hospitalization 
than were social class variables. Key differences were 
identified between isolates, those living with close rela- 
tives, and those living with distant relatives. Distant 
relative relational systems were less likely to try pre- 
alternatives, had less tolerance for symptoms, and acted 
most quickly to hospitalize the patient. Thus, patients 



43 

from this type of network presented with less serious 
symptoms at the time of admission. Interestingly, the most 
serious behaviors tended to be presented by isolates, pos- 
sibly due to the fact that they were publicly ignored until 
their condition was perceived as harmful to themselves or 
others. 

Precipitants were easily identified, with all but 23 
informants being able to isolate the factor that caused 
someone to conclude that the patient no longer belonged in 
his/her current environment. However, information as to the 
source of this initial label was not compiled. 

In terms of the referral process, the role of physi- 
cians was extensive, with their participating in at least 
three-fourths of all cases. However, a difference was noted 
in the source of the initial action, with personal or in- 
formal network members being responsible only 50% of the 
time. Correlates of this variable were only roughly identi- 
fied. Among patients living with others, the first action 
was most likely taken by those with whom they lived. Not 
surprisingly, for isolates the first action comes from 
formal sources. 

Once admitted to the psychiatric ward community dis- 
charge was unlikely, with only 15% returning home. Of 
significance here were the complexity of predisposing fac- 
tors, the duration of the condition, and the number of 
prealternatives tried. 



44 

Tobin and Lieberman (1976) examined both the process by 
which the elderly enter a long-term care institution and the 
effects of that decision on the elderly 1 s physical and 
mental well-being. The study design was longitudinal and 
incorporated community-based controls. Only mentally and 
physically able elderly were included in the sample 
(N = 88) . These elderly were found to be the primary agents 
controlling institutional entry, with family and social 
service personnel assisting in this process. While negative 
consequences of institutional entry were, in some part, 
explained by passivity and relocation, the primary negative 
health "effects" were shown to be characteristics that were 
already present in the new residents prior to their instu- 
tionalization. 

In a more limited study, Smyer (1980) also analyzed 
some key variables that discriminate between institutional- 
ization and community care of the elderly. Studied were 33 
client pairs (one from an intermediate care facility and one 
from a home care program) matched according to their level 
of functioning. Survey data were collected from the client, 
staff, and a family member or friend. 

Analysis indicated that the family's reported ability 
to care for the client was the primary key to avoiding 
institutionalization. Yet, poor client mental health and 
the number of previous contacts with other service agencies 
in the community were significant counter forces. 



45 



Interestingly, poor mental health rather than physical 
symptomatology was most stressful to the care-taking child, 
and, thus, in Lowenthal's terminology was a key institution- 
alization precipitant. The other counter force, number of 
community service contacts, implies that institutional- 
ization was preceded by a complicated process of searching 
for other alternatives. This is highly suggestive of the 
perception of the institution as the "option of last resort" 
rather than the help-rendering activity defined by Hammer 
(1963) . 

McKinlay (1973) explicitly examined the effects of 
social networks on lay consultation and help-seeking be- 
havior. Interviewed were 87 unskilled working class 
families (this was identified as an attempt to control for 
class variables) , 48 of which were classified as under- 
utilizers of maternity care and 39 of which were classified 
as utilizers. In essence, underutilizers rejected early 
prenatal care, using formal health services only in the end 
stages of their pregnancies when their "need" or the ser- 
iousness of their condition was the highest. 

Information was collected about specific network fields 
(i.e., kin and relatives) and about the total primary net- 
work (kin plus relatives) . The tests used were the t-test 
for continuous data and the cumulative chi-square test for 
categorical data. Several key trends emerged. Regular 



46 

utilizers of prenatal services visited with their relatives 
less frequently, perhaps indicating greater independence 
and/or intensity in their kinship network, and had a higher 
frequency of contact with their friends. Furthermore, util- 
izers appeared to have separate or differentiated kin and 
friendship networks, implying that their total networks were 
more open than the networks of nonutilizers. Thus it was 
shown that those utilizing maternity services when their 
condition was less serious had less contact with their 
relatives and more contact with what was identified as a 
differentiated friendship network. 

McKinlay also explored the source of consultation for 
various problems. In terms of health problems, key differ- 
ences emerged between utilizers and nonutilizers, with 
nonutilizers more likely to consult with their mothers or 
siblings for possible solutions and utilizers more likely to 
consult with nonrelatives and friends. However, as a rule, 
utilizers were less likely to consult with any primary 
network members before visiting a physician for recognized 
health problems in their children. In conclusion, McKinlay 
found some evidence that those maternity clients with an 
open friendship network and less intensive family network 
were more likely to define their "health problem" in medical 
terms and had an increased likelihood of an early referral, 
or medical visit. 



47 

Horwitz (1977) also examined the relationship of net- 
work variables to the help-seeking process. Labeling, re- 
ferral, problem severity, and problem duration were the 
dependent variables examined. Additionally, like Lowenthal, 
he attempted to compare the variable effects of network and 
cultural variables on the help-seeking process. In this 
vein, he subcategorized his sample of 120 patients at a 
community mental health center into members of social clas- 
ses III and IV — the middle and working classes on the 
Hollingshead index. While the patients were the primary 
data source, a number of their network members were also 
interviewed to serve as reliability cross checks. The 
patients medical records were examined for this same 
purpose. 

Like McKinlay, Horwitz segregated ego's primary network 
into fields and collected both subnetwork and total network 
data. Once again, a frequency measure was used as an indi- 
cator of family network strength or intensity. Similarly, 
as in the McKinlay study, respondents' self definitions were 
used to determine their friendship network; however, in this 
case only ego's three closest friends were included. Thus, 
friendship measures were based upon this self-defined, ab- 
breviated friendship network. Testing was done via multiple 
regression analysis, with categorical independent variables 
treated as dummy variables. 



48 

In general, while there was a tendency for people with 
strong kin groups and closed friendship networks to be 
insulated from formal labels, no significant findings 
emerged in terms of either network or cultural variables and 
the labeling and referral process. However, when network 
members were further identified as communicating either 
positive or negative information about psychiatric treat- 
ment, it was shown that having a "positive" network member 
was positively related to informal labeling and referral. 
Thus, it was not enough for ego's network to be open and 
thus more likely to be informed of psychiatric care, the 
network also had to communicate positive information to ego 
about these services. 

Although Horwitz did not pursue his data to this point, 
these results hint at a possible interactive effect between 
network variables and cultural variables; i.e., controlling 
for the quality of information received by ego (positive or 
negative) , the strength of association between density and 
informal referral will vary. If the information received is 
positive, there is likely to be a strong positive associ- 
ation between network openness and informal labeling and 
referral. However, if the information received is negative, 
this association is likely to be weaker or insignificant. 

Stronger findings emerged in terms of social network 
variables and the severity of ego's presenting condition. 
When ego had strong kin and closed friendship networks, 



49 



treatment was delayed until symptoms became severe. Inter- 
estingly, the relationship between class variables and sev- 
erity was insignificant. As explained by Horwitz 
(1977:96-97) , 

The strong kin group supports the person within the 
primary network while closed or absent friendship 
structures make information about psychiatry less 
accessible. This group is the most likely to enter 
treatment after dramatic incidents such as suicide 
attempts or psychotic breaks. On the other hand, 
people with weak kin groups and open friendship 
networks do not receive strong internal support 
but have the ability to connect to psychiatric 
resources and they readily enter treatment with 
mild conditions. 

The findings in terms of duration were somewhat con- 
fusing: (1) There was no relationship between social class 
variables and duration. (2) Persons with weak kin networks 
and open friendship networks entered treatment most rapidly. 
(3) Persons with weak kin networks and closed friendship 
networks had the longest duration of symptoms. (4) Persons 
with strong kin networks and closed friendship networks had 
a duration approximately equivalent to the sample mean. 
However, as the method of determining these data was not 
explained, one's interpretation can only be based on assump- 
tions. More than likely, inaccuracies in duration data 
account for most of the confusion in these results. As 
pointed out in the Lowenthal-Fiske (1964) study, the com- 
plexity of preadmission symptomatology is significant, with 
involvement of both predisposing and precipitating factors. 



50 

Thus, reliable and valid duration data can only be gleaned 
from careful specification of the source from which duration 
will begin to be computed. 

Perrucci and Targ (1982) also studied the process of 
mental institutionalization from a network perspective. 
Specifically examined were the processes of labeling and 
referral as functions of network density, size, and inten- 
sity. A small sample of the networks of 45 hospitalized 
persons was interviewed to enable data collection from all 
identified network members. 

Concept operationalization was unconventional. Density 
was based on frequency of contact, not on the proportion of 
theoretically possible direct ties. Openness, measured 
separately, was measured by number of existing ties with 
nonfamily members. Finally, closeness or intensity, was 
considered as a nominal variable, with a network categorized 
as nonintense when the same person was not nominated by 
network members more than once as having close ties with 
ego. The two conflicting measures of density are confusing, 
and although neither is consistent with measures used in 
other studies, as the later seems more in tune with the 
theoretical meaning of the concept it will be used in result 
summarization. 

Similar to previous findings, those patients with 
small, closed networks tended to be insulated from formal 
labels. Furthermore, their networks were slower to seek 



51 



help, resulting in longer symptom duration prior to hospi- 
talization. Alternatively, those with open networks were 
more likely to define their health problems in medical terms 
and seek early hospitalization. 

In terms of network intensity, Perrucci and Targ's 
findings support results obtained by Hammer (1963) . It 
seems that hospitalization was defined as a way to help ego. 
Thus, networks with close, intensive relationships with ego 
acted quickly to bring ego's perceived problem to medical 
attention and to hospitalize ego. Alternatively, in the 
studies by Lowenthal-Fiske (1964), McKinlay (1973), and 
Horwitz (1977) , the seeking of medical services and hospi- 
talization of ego was not as positively perceived accounting 
for the reported inverse relationship between network inten- 
sity and the speed of referral and hospitalization. 

While a large portion of the study done by Sokolovsky 
and associates (1978) of former mental hospital patients 
residing in a Manhattan Single Room Occupancy (SRO) hotel 
was devoted to analyzing the structural differences between 
the networks of people exhibiting different degrees of 
schizophrenic symptomatology — and thus is not particularly 
relevant to the proposed study — it bears mentioning due to 
both the conclusions it reached on the relationship between 
social network characteristics and rehospitalization and its 
methodological approach. 



52 

The sample was small, consisting of only 41 SRO resi- 
dents. However, as the geographic area was restricted to 
one hotel, a combination of participant observation and 
interviewing permitted greater data accuracy. Both chi- 
square tests and one-way analysis of variance were used for 
data analysis. It was shown that those residents who were 
not frequently re-admitted into psychiatric hospitals had a 
significantly higher number of multiplex relationships and 
their personal networks were significantly higher in density 
and size. Thus, network characteristics served a supportive 
role delaying or preventing reinstitutionalization. Fur- 
thermore, following previous lines of reasoning, it is prob- 
able that if those with supportive networks were eventually 
reinstitutionalized their presenting symptomatology would 
likely be much more severe. 

Of particular methodological interest, was this study's 
nonutilization of friendship categories in the delineation 
of network fields. Rather, such fields as tenant-tenant and 
tenant-nontenant were used, with membership based upon con- 
tact criteria, with only links active within the prior year 
and with a contact frequency of once every three months 
included. 

This approach was based on the premise that the concept 
of friendship is theoretically and empirically meaningless. 
Support for this position is demonstrated both in their 
study and in the future studies of Creecy and Wright (1979) 



53 



and Cohen and Rajkowski (1982) , which reveal that normative 
second-order constructs of friendship may bear no relation- 
ship to the definitions in use by study respondents. 
Sokolovsky and his associates' 1978 study found self-pro- 
claimed loners who, while denying friends, had large complex 
networks involving an assortment of material and instru- 
mental exchanges. On the other extreme, Creecy and Wright 
found among their black rural native elderly a very non- 
restrictive operating definition of friendship. In this 
sample it seemed that friendship was equated with friendli- 
ness, and thus required minimal social obligations. Finally, 
in another SRO-based study, Cohen and Rajkowski (1982) found 
that for their elderly population the label of friendship 
was not determinative of either the existence or absence of 
emotion and/or material exchanges. 

Wentowski (1981) also explored the process of social 
exchange within the respondents' personal networks. Like 
Sokolovsky and his associates, a combination of participant 
observation and extensive interviewing was used for data 
collection. However, her sample was purposively chosen to 
be representative of the elderly population living in a 
community setting. 

Fieldwork supported the function of social exchanges in 
role formation. Interestingly, Wentowski described how 
different exchange strategies are used to outline the degree 



54 

of interpersonal commitment desired in a relationship by the 
respective parties. While an "immediate" exchange strategy 
(usually instrumental, strictly balanced, and with an imper- 
sonal exchange medium) is conducive to maintaining social 
distance between people, a deferred strategy is "a form of 
balanced reciprocity which can be used to express a willing- 
ness to trust and to assume greater obligation" (Wentowski, 
1981:604) . 

Wentowski' s analysis emphasized the importance of bal- 
anced reciprocity in the maintenance of interpersonal rela- 
tionships. Additionally, balance was recognized as an es- 
sential contributor to the self-esteem and pride of elderly 
people and also as "the major means of guaranteeing security 
in old age" (Wentowski, 1981:605). Along these latter 
lines, Wentowski identified the importance of building up 
"credit" through giving of oneself to others — either in 
terms of material or psychological resources. In this man- 
ner deferred obligations can be accumulated, thus giving the 
elderly a "right" to expect help from these others when and 
if they need it. 

Although Wentowski did not specifically explore the 
function of reciprocity in the process of institutional- 
ization, her analysis lends support to propositions con- 
tending that the existence of reciprocal relationships fa- 
cilitates delayed institutionalization (and hence when in- 
stitutionalization occurs the presenting illness will be 



55 



more severe) and makes the possibility of deinstitutional- 
ization more likely. 

Both reciprocity and affection were the focus of 
Horowitz and Shindelman's (1983) study of the variances in 
caregiving to the frail elderly in the home by the primary 
caregiver. Interviews with 203 New York City primary care- 
givers indicated that reciprocity and affection were the 
chief reasons for helping a frail older network member in 
need of care. Furthermore, both of these variables were 
positively correlated with the degree of caregiving extended 
by the primary caregiver. Affection was also negatively 
correlated to the level of perceived stress by that 
caregiver. However, this study was limited in that it only 
looked at the relationship with the primary caregiver and 
that it failed to control for any of the cultural or struc- 
tural characteristics of the focal population. 

Vaghn and Leff (1976) and Brown et al. (1972) also 
examined the influence of social variables on the probabil- 
ity of mental hospital readmission. However, as they looked 
at the quality of expatients' family relationships rather 
than the structure of their networks, their focus was dif- 
ferent than that of Sokolovsky et al. (1978). In both 
studies, Brown and colleagues 1 index of emotional response 
(a composite of the number of critical comments of someone 
else in the home, hostility, dissatisfaction, warmth, and 



56 

emotional overinvolvement) was found to be the best single 
predictor of patient symptomatic relapse (with the relation- 
ship in a negative direction) , even when controlling for the 
patient's clinical condition at the time of admission. Al- 
though the index of emotional response is a qualitatively 
different variable than intensity, which is the focal inter- 
actional variable in the proposed study, their findings do 
alert one to the importance of both structural and inter- 
actional variables in the course of institutionalization and 
thus are worth noting. 

In a study of much larger scope than those reviewed to 
this point, Wan and Weissert (1981) examined the relation- 
ship of social support networks (measured as numbers of 
relatives and friends in contact with the elderly person) to 
three dependent variables relevant to the process of insti- 
tutionalization: (a) the health status of the impaired 
elderly; (b) the probability of being institutionalized; and 
(c) length of stay in an institution. Data were obtained on 
1,119 impaired elderly over a four-year period. Of special 
import was the fact that this group initially was not insti- 
tutionalized. Thus, a comparison group of those who were 
not instititutionalized during the course of the study was 
available. 

Significant relationships were demonstrated between 
social support networks and each of these variables. Those 
with a low number of sources for social support had 



57 



significantly worse physical and mental health at the end of 
the demonstration period than those with a high number of 
social support sources. The probability of being institu- 
tionalized was related to living alone vs. living with 
others; and length of stay in an institution was related to 
the impaired elderly having children, siblings, or grand- 
children in their social support networks. 

However, while the study was somewhat more sophis- 
ticated than those others mentioned to this point, due to 
its sample size and utilization of extensive multiple re- 
gression equations, the validity of its social support indi- 
cator is questionable. It is likely that all of the 
impaired elderly 1 s relatives and friends are not providing 
them with useful and/or valued support services. 

In a related vein, Wells and MacDonald (1981) examined 
the relationship of the elderly' s network to the process of 
interinstitutional relocation. Longitudinal data were col- 
lected on 56 extended-care residents of one of Toronto's 
homes for the aged prior to and 8-12 weeks following non- 
voluntary movement of the residents to a similar type of 
care facility. Network information was obtained on the 
number of "close" residents, staff, and family and nonresi- 
dent friends that were in the residents' networks both 
before and after the move occurred. Not surprisingly, relo- 
cation had a disruptive effect on primary relationships, 



58 

with the mean number of primary ties identified by the 
residents dropping from 4.2 to 2.9, a change significant at 
p < .0001. However, this loss was mainly reflective of the 
loss of close relationships with the residents and staff 
from the former home. There was no significant change in 
their number of close family and nonresident friends. 

Other examined consequences of relocation (declines in 
life satisfaction and psychological deterioration) , while 
found to be significant, can be less readily attributable to 
the relocation process as the study failed to incorporate a 
control group in its design. The number of close non- 
resident friends and family, and staff relationships engaged 
in by the resident was associated with successful readjust- 
ment to relocation in terms of life satisfaction and physi- 
cal and mental functioning. Hence, it seems that engagement 
in primary relationships functioned somewhat as a buffer of 
the examined negative relocation consequences. 

The seminal study by Borup and associates (1978) on 
interinstitutional geriatric relocation was not limited by 
the lack of a control group. An experimental design was 
used to study the effects of forced relocation on 529 of 
Utah's nursing home residents. The control group consisted 
of 19 randomly selected homes that were not undergoing 
relocation, yielding 453 respondents. Thus, the combined 
sample size was 982. 



59 

A breadth of consequences were studied, including the 
effects of forced relocation on the resident's life satis- 
faction, self-concept, sense of security, network, and 
health. Data were collected three to six months prior to 
the move and up to six months after relocation. Their 
conclusion was interesting and controversial. 

The move itself is a stressful experience and 
has emotional overtones for many patients. 
However, that experience is not of such a 
nature that it has negative effects beyond the 
experience itself. The findings of this study 
overwhelmingly support the proposition that 
relocation either has no effect or a positive 
effect with respect to the variables studied. 
(1973:172) 

Furthermore, in a later article (1982) , when Borup reexam- 
ined these effects in terms of the degree of environmental 
change experienced by the residents, even those residents 
experiencing the most radical environmental changes wit- 
nessed no significant negative consequences in any of these 
areas. 

Of special interest in terms of this study was the 
effect of relocation on the residents' networks. Unlike the 
conclusions of the Wells and MacDonald study (1981) , Borup 
et al. (1978) found that relocation did not influence the 
number of residents who had friendship ties within the 
nursing home setting nor did it alter the resident's fa- 
milial network system. It seems that the residents who were 
able to form friends at the old home tended to retain that 
ability after they moved. Thus, while the content of their 



60 



friendship network changed, size was stable. Significant 
declines in internal friendships did occur over this period 
in both control and experimental groups. However, as the 
intergroup differences were not significant, the declines 
are best attributed to the aging process, rather than relo- 
cation. Similar results occurred in terms of the other 
variables studied. When significant declines did occur in 
the relocated group, these declines were also experienced in 
the nonrelocated group, thus implying that relocation was 
not the precipitant. 

Rundall and Evashwick (1982) also studied the relation- 
ship of network variables to the elderly 's illness behavior. 
Sampled were 883 noninstitutionalized elderly. As in the 
work of Hammer (1963) and Perrucci and Targ (1982) , health 
care utilization was conceptualized as a type of help 
seeking. In this case the focus was on such illness behav- 
iors as length of time since one's last visit to a physician 
and the number of one's visits to a doctor in the past year. 
Of interest was the relationship of ego's level of satis- 
faction with his/her network to the use of professional 
services. Thus, the key independent variable was ego's 
perception of the condition of his/her network. 

Information was collected on both relative and friend- 
ship networks, although the operationalization of friendship 
is unclear. Interestingly, while ego's satisfaction with 



61 

his/her friendship network was unrelated to utilization 
behavior, ego's perception of his/her relative network was 
significantly related to utilization behavior, even when 
controlling for perceived health status. Engagement, i.e., 
visiting one's relatives at least a few times a week and 
wanting to visit with them as much or more than one cur- 
rently does, was positively related to the use of services 
and thus understood as a determinant of help-rendering 
activities. In contrast, disengagement and abandonment were 
negatively related to the use of services and thus under- 
stood to indicate conditions where individuals were less 
likely to have networks that facilitated their health care 
utilization. 

While Scheff (1966) did not specifically examine the 
effect of social network variables on the process of insti- 
tutionalization, his research did test the related hypo- 
thesis that social contingencies external to ego are crucial 
determinants in the process of becoming mentally ill. In 
this regard, labeling, the acquisition of the role of mental 
illness, hospitalization, and discharge are all identified 
as consequences of such social factors as the power of the 
rule breaker, the social distance between him/her and the 
agents of social control, the tolerance of the community, 
and the availability in the culture of the community of 
alternative nondeviant roles. 



62 

Scheff's study (1966) on the release plans for patients 
hospitalized in mental health facilities in a Midwestern 
state is an explicit test of this theory. A sample of 555 
patients along with the hospital official legally respon- 
sible for patient care were surveyed for information regard- 
ing the patient's mental health state, social variables, and 
plans for the patient's release. Results supported his 
hypothesis. Controlling for the patient's degree of medical 
impairment, patient release plans were explained by (1) the 
type of hospital where the patient was located and (2) the 
length of the patient's confinement. 

Allison-Cooke's (1982) review and analysis of the pat- 
tern of deinstitutionalization within Rhode Island's nursing 
home system also supports the effect of "external contingen- 
cies" on deinstitutionalization. In spite of an elaborate 
system operating to assess the appropriateness of medicaid- 
supported patient placement within the nursing home system 
and the feasibility of community relocation, in the course 
of a one-year period fewer than 1% of the patients at any 
level of care (skilled nursing facility, intermediate care 
1, or intermediate care 2) were recommended for transfers to 
acute hospitals, to return home, or to move to some other 
type of care setting. This finding is particularly in- 
triguing due to the fact that only 7.8% of the nearly 1,000 
patients receiving intermediate care 2 were classified as 
displaying "an appreciable need" for institutionalized care. 



63 



Although Allison-Cooke 1 s explanation for this is specu- 
lative, such contingencies as fear of potential relocation 
trauma; possible family resistance; assessment team limita- 
tions in the availability, assessibility, and knowledge of 
alternative services; and systemic fragmentation are pro- 
posed as possible explanations. Once again, the theme of 
the importance of the resident or patient's network in the 
deinstitutionalization process is sounded. 

Greenley (1972) also studied the relationship between 
the timing of a patient's release from a state mental hospi- 
tal and contingencies external to the patient's health 
status. His focus was on the impact a patient's family may 
have on his/her length of stay. Along this line, the key 
independent variable identified was the family's desire for 
the patient's release. Again, while this is not a network 
variable, as discussed in Chapter Three, the family's desire 
for the patient's release may be theorized to be a direct 
consequence of the network variables — density, reciprocity 
and intensity. 

Longitudinal data were collected from 100 patients, 
their closest family member, and their psychiatrist via 
interviews, observation, and medical record review. Of the 
multiple measures of health status obtained, only the psy- 
chiatrist's judgments on the patient's level of psychiatric 
impairment and need for hospitalization were significantly 



64 

related to his/her length of hospitalization. Neither meas- 
ures of dangerousness nor standardized symptomatology meas- 
ures were significant length of stay predictors. Interest- 
ingly, the relationship between family desires and length of 
stay was stronger than that of any of the illness measures. 
Furthermore, when each of these measures was controlled for 
family, desires were still found to be significantly related 
to length of stay. 

In conclusion, based on theory and previous research 
the following propositions were examined: 

1. The density of ego's primary network is directly 
related to 

a. the duration of his/her network ties; 

b. the severity of ego's health status at the 
time of ACLF entry; 

c. the likelihood of ego's problem being 
labeled by a professional; 

d. the likelihood of ego's being referred to 
an ACLF by a professional; and 

e. the likelihood of ego's being relocated 
from the ACLF to the home of ego or to 
the home of one of the members of ego's 
primary network. 

2. The intensity of ego's primary network ties is 
directly related to 

a. the duration of his/her network ties; 

b. the severity of ego's health at the time of 
ACLF entry; 

c. the likelihood of ego's problem being labeled 
by a professional; and 



65 



d. the likelihood of ego's being relocated 

from the ACLF to the home of ego or to the 
home of one of the members of ego's network. 

3. The proportion of reciprocal ties in ego's network 

is directly related to 

a. the duration of his/her network ties; 

b. the severity of ego's health at the time 
of ACLF entry; 

c. the likelihood of ego's problem being 
labeled by a professional; and 

d. the likelihood of ego's being relocated 
from the ACLF to the home of one of the 
members of ego's primary network. 

These propositions are also represented in the 

following general equations* and illustrated in Figure 4-1: 

1. Labeling by a Professional = Density + Intensity 

+ Reciprocity + Sex + SES + Race. 

2. Referral by a Professional = Density + Sex 

+ SES + Race. 

3. Severity of Health at Time 1 = Density + Intensity 

+ Reciprocity + Sex + SES + Race. 



*Each of these equations was also computed with degree data 
substituted for density data, perceived balance substituted 
for reciprocity, physical health substituted for mental 
health and both closest other and network intensity data. 
The focal networks included total primary, relative, and 
nonrelative networks. 



66 

4. Tie Duration = Density + Intensity + Reciprocity 

+ Sex + SES + Race + Severity of Health 
at Time 2. 

5. Relocation to Home = Density + Intensity 

+ Reciprocity + Sex + SES + Severity of 
Health at Time 2 + Race. 



67 



Labeling by a 
professional ^ 



Severity of health 



Tie duration 



Relocation to home 




Intensity, 
reciprocity, 
density, and 
degree 



Referral by a professional ^- 



Density and 
degree 



Figure 4-1. Hypothesized effects of network variables 
on ACLF relocation 



CHAPTER FIVE 
DATA AND METHODS 



Sampling and Data Collection 

The study's sample consisted of those residents aged 60 
and older who were new to ACLFs (less than two months resi- 
dency) . Sampling was limited to Orange and Seminole 
Counties, Florida. A longitudinal design was implemented, 
with phase one beginning in June and ending in September 
1985 and phase two beginning in December and ending in 
March, 1986. Thus, there was a six-month lag between Time 1 
and Time 2 data collection. 

As the size of the ACLF was not a theoretically impor- 
tant variable in this study, the researcher arbitrarily 
decided to study only those residents of ACLFs whose total 
licensed capacity was less than or equal to 50 residents. 
This excluded seven institutions licensed for 65, 90, 95, 
150, 188, 250, and 350 beds, respectively. 

Forty-nine facilities met this restriction. Of these, 
two refused access to the researcher (a 15-bed and a 34-bed 
facility) and one allowed only limited access (a 34-bed 
facility) . Of the remaining 46 facilities, 30 had at least 
one new resident during the intake phase of the study. All 
of these were visited, resulting in a total sample size at 
Time 1 of 85 residents. 

68 



69 



Of interest were both the resident (otherwise referred 
to as ego) and the resident's primary or ego-centered net- 
works. To this end, Time 1 data were collected via personal 
interviews with new residents, ACLF caregivers, and ego's 
closest available other (otherwise referred to as alter) . 
The reasons for this strategy were multiple. First, as 
discussed in Streib (1983) , it was anticipated that many 
residents would not have sufficient cognitive ability to 
respond accurately to the questionnaire. Thus, it was nec- 
essary to plan systematically for an alternative survey 
respondent. Ego's "closest" available other was felt to be 
the most accurate substitute. 

To analyze the appropriateness of this substitution, 
matching data from alter was sought for each resident at 
Time 1, allowing paired t-tests to be done to determine any 
differences between obtained ego and alter responses. If 
ego was cognitively able, he/she identified alter and gave 
the researcher permission to contact alter and information 
on how to do so. If ego was unable to supply this informa- 
tion, it was obtained from his/her caregiver. 

The second reason for using multiple informants was due 
to the predicted involvement of ego's network in his/her 
relocation. Information of this process from the network's 
perspective was, thus, also theoretically valuable. And, 
finally, data from the caregivers were obtained in regard to 



70 

ego's current self-care abilities as they were assumed to be 
the most knowledgeable and objective sources of this infor- 
mation. 

While it was recognized that the "key informant ap- 
proach" to information about ego's network would undoubtedly 
"slant the truth" in the direction of ego's (or ego's clos- 
est other's) perceptions, it was not economically feasible 
to interview all of the identified members of ego's primary 
network. Furthermore, it is a common and valid research 
alternative to utilize informants for this information when 
it is not feasible for the subject to be observed or ques- 
tioned directly (Dean and Whyte, 1969) . Additionally, as 
Becker so aptly argues, "The question is not whether we 
should take sides, since we inevitably will, but rather 
whose side we are on. . . . We must always look at the 
matter from someone's point of view" (1970:15,22). 

Thus, network data obtained in this manner could not 
help but be biased from the informant's perspective. Yet, 
the reliability and validity of this method of data collec- 
tion was maximized by (1) quashing ulterior motives of the 
informant, (2) reducing bars to spontaneity, and (3) cross 
checking the account of an informant with the account of 
other informants. Ulterior motives were quashed by ex- 
plaining to the informants that the researcher was in no 
position to alter the existing situation. Bars to sponta- 
neity were lifted by assuring the informants of 



71 



confidentiality and conducting interviews in a private 
setting. And, cross checking was done when ego was the 
primary informant by also interviewing ego's closest network 
member about information regarding ego's primary zone and 
the process by which ego was relocated to an ACLF. 

This combined strategy was successful in that only four 
of the initial sample were dropped from the study at phase 
one, resulting in a completion rate of 95.2%. Thus, most of 
Streib's (1983:42) "excluded 20%" were included in this 
study. Nonresponses were due to the combined circumstances 
of mental incompetence of the resident and participation 
refusal of ego's closest available other. An assessment of 
ego's self-care abilities was obtained from caregivers for 
all of the respondents. Thus, 81 surveys were completed by 
either the resident or his/her closest other yielding a 
total sample size at Time 1 of 81. 

Of this remaining sample, six surveys were not cross 
checked due to alter nonaccessability. Access was either 
denied by the respondent (2), or by alter (2), or it was 
limited due to the unavailability of a local significant 
other (2) . Thus, 75 alters were interviewed during the 
intake phase of the study. All but five of these were face- 
to-face interviews. Phone interviews were conducted due to 
preference of the significant other (4) or distance of alter 
from Orange County (1) . 



72 

Twenty-eight residents (34%) were not able to complete 
the survey at Time 1 due to mental incompetence (26) or 
physical infirmities (2). Ego's mental capacity was as- 
sessed at the onset of the interview (after obtaining in- 
formed consent) via a modified version of Pfeiffer's Short 
Portable Mental Status Questionnaire (1975) . The tool was 
situationally adapted to the ACLF population by substituting 
Pfeiffer's question, "What is your telephone number?" and 
its alternative for those without a telephone, "What is your 
street address?" with the question, "In which room do you 
live?" 

The Short Portable Mental Status Questionnaire has been 
specifically designed as a gross test of intellectual func- 
tioning for use on the elderly population. In addition to 
its suitability for the population of the proposed study 
other key advantages include its brevity and ease of port- 
ability (see Appendix B) . Only ten questions are asked of 
each subject. Five primary aspects of mental functioning 
are addressed: short-term memory, long-term memory, ori- 
entation to surroundings, information about current events, 
and the capacity to perform serial mathematical tasks. 
Field testing was done by Pfeiffer (1975) with a population 
of 926 subjects. As his analysis suggested that both educa- 
tion and race influenced performance, they are adjusted for 
in score evaluation. Scores are then coded into four dis- 
tinct levels of intellectual functioning: intact 



73 



intellectual functioning (0) , mild (or borderline) intel- 
lectual impairment (1) , moderate (or definite) impairment 
(2) , and severe impairment (3) . 

Pfeiffer's interpretation of these levels was useful in 
determining the respondent's ability to respond accurately 
to the research questionnaire. If ego's intellectual abili- 
ty was measured to be intact or only mildly impaired, ego 
was considered the primary survey informant and the inter- 
view was continued. However, if ego's mental functioning 
was measured as either moderately or severely impaired, the 
interview was terminated and the person closest to ego, as 
identified by staff and/or ego, who was accessible for 
interviewing was contacted and considered to be the primary 
informant for these data. 

Personal interviews with ego and alter at Time 1 set 
the stage for follow-up data collection at Time 2. Initial 
interviews were conducted in a leisurely, nonthreatening 
manner in to facilitate rapport and the establishment of 
trust with the respondent. Generally, alter was interviewed 
in his/her home, with occasional contacts occurring over 
alter 's lunch hour. Frequently the researcher reframed her 
role by bringing her infant along. Given the nature of the 
population (both ego and alter were both generally elderly 
women), this novel approach was an effective "ice breaker." 



74 

These strategies both maximized data quality at Time 1 
and minimized the respondent drop out rate at Time 2. Al- 
though six of the respondents were lost to the study at 
Time 2 due to their deaths, only one was lost due to respon- 
dent refusal at Time 2. This refusal was not surprising, 
because it came from a "closest other" who had also refused 
to participate in the study at Time 1. While ego's respon- 
ses were available at Time 1 (and hence substituted for 
alter *s) ego had moved into an unidentified nursing home at 
Time 2 and hence was not contactable by the researcher. 
Additionally, only partial follow-up network information was 
available on three residents who had moved out of the area, 
due to alter 's lack of knowledge of this information. 

An alternative strategy was used for data collection at 
Time 2. While a follow-up contact with ego was attempted 
for all of the original respondents, alter was only recon- 
tacted if ego's mental or physical status prevented valid 
survey completion (n = 26) , if ego had moved to an out-of- 
town location (n = 3) , or if the family preferred that the 
researcher contact them rather then ego (n = 2) . The ra- 
tionale for this diminutive approach was that ego and ego's 
current caregiver were the persons closest to and hence most 
valid sources of the data sought at Time 2. (The focus at 
Time 2 was on ego's health, perception of person-environment 
fit, and network ties.) And, as the closeness of fit by 
substitute alter responses had already been determined by 



75 



matching ego and alter responses at Time 1 this did not need 
to be repeated at Time 2 . 

With one exception (this person was hard of hearing, 
and could better understand the researcher when visual con- 
tact was present) , alter contacts at Time 2 were via tele- 
phone interview, rather than face-to-face contact. Phone 
interviews were the method of choice for this phase, as it 
was determined that such potential compromises to data qual- 
ity as increased refusal rates and greater interviewer re- 
spondent social distance would be slight, due to the care 
taken at time one to establish a comfortable relationship 
with the respondent, and the economic savings would be 
significant (Frey, 1983) . Furthermore, phone interviews 
were more convenient for ego's closest other as well, de- 
manding less time and effort on their parts. Hence, the 
interviews were more likely to be favorably received. 

Network Del i mi ha hi on 
Network delimitation attempted to define ego's inner 
circle of contacts — those people with whom ego was actively 
tied emotionally and/or via material exchanges. Wellman's 
(1981) relational criteria of contact frequency, tie con- 
tent, and tie intimacy were the critical elements used for 
boundary definition. Both relative and nonrelative fields 
were delineated to allow for analysis of both ego's total 
primary network and key primary network subfields. This 



76 



strategy was followed in lieu of Cubbitt's (1973) obser- 
vation that general network characteristics may mask signi- 
ficant different characteristics in sections of the network. 

Data were obtained via a two-phased approach. Respon- 
dents were first asked to identify two groups of people that 
ego had been in contact with on a regular basis during the 
past year. The first group was to consist of relatives, and 
the second included nonrelative adults (excluding residents 
at the ACLF) that ego felt close to. 

Ego and alter were then asked a series of questions 
about each of these people to determine how frequently they 
were in contact, how emotionally bonded ego was to them, and 
how many material links they shared. Ego was considered the 
primary informant for all network data, as alter was not as 
likely to know of all of ego's close contacts, and alter' s 
responses were substituted as necessary. If minimal in- 
clusionary criteria were not met for any identified person, 
he/she was then excluded from ego's inner circle of con- 
tacts. In this manner, ego and alter 's perceptions were 
"fine tuned" resulting in a more standardized delimitation 
of ego's inner circle. Interestingly, only twelve respon- 
dent-identified others did not meet these criteria, and thus 
were dropped from ego's inner circle. 

In terms of contact frequency, ego needed to be in 
contact with an identified other at least several times 



77 

during the past year to be considered a member of ego's 
inner circle. "Several times" was defined as existing be- 
tween once a year and every other month on a continuum from 
no contact to daily contact. To account for the mobility of 
our urban society (Adams r 1967) and the probable neighbor- 
hood boundedness of many of the resident's peer friends and 
family (Cantor, 1979) , a contact was not restricted to vis- 
iting. Rather, a contact was considered to be made if the 
resident received a phone call, a letter, or a visit from 
alter. 

Emotional Bondedness is a construct comprised of three 
components: (a) The sense that one receives emotional sup- 
port from another, (b) the sense of mutual sharing with 
another, and (c) feelings of positive affect with another. 
Constuct operationalization was accomplished via Snow and 
Crapo's Emotional Bondedness Scale (1982). This gave the 
researcher a method of quantifying the degree of social 
distance between ego and a network member, thus operation- 
alizing the degree of friendship in a relationship and the 
degree of closeness in relative links. The scale is a 12- 
item cumulative ordinal scale with scores varying from 1-3 
for each item. Thus, the total bondedness score can range 
from 12-36 (see Appendix A) . 

To meet minimal inclusionary criteria, a bond score of 
at least 24 (indicating ego and alter were at least "some- 
what" bonded) was necessary or at least one material link 



78 



needed to be identified. Material links were defined in 
terms of the existence of any one of three types of assis- 
tance: personal assistance, money or loans, or other gifts. 
As links can flow both to and from ego, data on both instru- 
mental and dependent links were obtained, yielding a poten- 
tial range of 0-3 material links between ego and a network 
member. 

Measurement of Dependent Variables 
Five dependent variables were identified: (1) the 
duration of ego's network ties, (2) the source of the label 
of ego's problem, (3) the severity of ego's health status at 
the time of ACLF entry, (4) the source of ego's referral to 
an ACLF, and (5) the likelihood of ego's being relocated 
from the ACLF to his/her home or the home of a network 
member . 

The duration of ego's social ties was measured with 
longitudinal data. As mentioned earlier, there was a six- 
month lag between initial and follow-up phases of the study. 
While it was recognized that this relatively short interval 
may not be a sufficient time period to assess the duration 
of ego's social ties, it was believed that at this point 
some trends in the data would be detected. Furthermore, as 
it is generally recognized that this population is rela- 



79 

tively unstable, it was determined that a short lag period 
would facilitate follow-up data collection and might help 
minimize study dropouts. 

Changes in mean network frequency of contact and the 
mean number of material links between ego and each of 
his/her primary network members from Time 1 and Time 2 as 
reported by ego (with alter substitutions as necessary) were 
the indicators of this variable. Data on contact frequency 
(visiting f speaking, and exchanging letters) at Time 1 were 
obtained by asking the respondent three questions: "On 
average, about how often have you (ego) seen, spoken to or 
exchanged letters with (insert name of each identified net- 
work member) during the past year?" Eight different cate- 
gories emerged for each type of contact (visiting, speaking, 
and writing) pattern at Time 1: not in the last year (0), 
one time a year (1) , several times a year (2) , every other 
month (3) , monthly (4) , every other week (5) , weekly (6) , 
several times a week (7) , and daily (8) . 

At Time 2 a similar question was used. As only a six- 
month time period was assessed, it was necessary to cate- 
gorize the data slightly differently. The first three cate- 
gories were contracted into two: Not at all (1) and once or 
twice (2) — with the others unchanged. A mean total network 
contact score and subnetwork contact scores were obtained 
for Time 1 and Time 2 data by summing ego's contact scores 
with each network member and then dividing by network size. 



80 



Measurement of tie duration with data on material links 
was accomplished by determining the presence or absence of 
three different types of material links (personal assis- 
tance, gifts, and financial assistance) from ego to each 
network member and then from each network member to ego. 
Links could, thus, be reciprocated, dependent, or instru- 
mental. A range of zero to three links was possible per 
tie. The mean number of network links was obtained by 
summing the material links between ego and each network 
member and then dividing by network size. Once again, this 
was computed for both ego's total network and network sub- 
fields. 

Dependent variables 2,3, and 4 all refer to the pro- 
cess by which ego's relocation was orchestrated. Data on 
this process were gathered via open-ended and closed ques- 
tions. Open-ended questioning was used at the beginning of 
the interview to "allow ego and alter to talk." The reasons 
for this approach were multiple. First, it was felt that 
given the potential stressf ulness of ego's move, allowing 
the respondent to ventilate his/her feelings would be thera- 
peutic. Hence, this was a way of reciprocating the respon- 
dent's contribution to the researcher's study. Secondly, by 
making time to listen to the respondents' concerns the 
researcher was able to demonstrate interest in them as peo- 
ple, not simply as potential sources of data. This 



81 



facilitated rapport and a sense of trust. Third, as little 
was known about this process, leaving some of the questions 
open-ended allowed for a potentially greater generation of 
new knowledge. 

Close-ended questions were then used to determine an- 
swers for questions with a few, discrete responses. Thus, 
information on such questions as (1) Who had first labeled 
ego's condition as "out of place" in his/her current living 
situation, (2) who had suggested relocating ego into an 
ACLF, and (3) what was ego's current level of self-care 
abilities was obtained in this manner. 

As noted earlier, both ego's and alter 's perceptions of 
the process of ACLF entry were of interest. Yet, it was 
recognized that as ego's network was probably the primary 
coordinator of the move, alter 's responses would generally 
be closest to "the truth." Thus, data on each of these 
variables were tabulated in three ways: using ego responses 
only, using alter responses only, and with alter as the 
primary informant, using ego substitutes as necessary, when 
both ego and alter responses were available, a chi-square 
analysis was done to test for significant between-source 
differences. Additionally, ego's primary caregiver was the 
source of data on ego's current self-care abilities. 

In terms of ACLF relocation, ego's "problem" was basi- 
cally one of increased dependence. Essentially, ego's con- 



82 

dition came to be perceived as one that no longer 
"comfortably fit" in his/her current environment. The key 
variable identified here was the primary source of this 
label. This was determined by asking the respondent, "Who 
first suggested that you (ego) might have to move into 
another living situation?" Five rather specific responses 
were possible: "a relative" (0) , "a personal contact" (1) , 
"your doctor" (2), "you determined it yourself" (3), and 
"another health professional" (4). These were then aggre- 
gated into formal (2 and 4) and informal (0, 1, and 3) 
categories, as in the work of Horwitz (1977) . 

While the perception of a change in ego's condition may 
be understood as a trigger for action, it was understood 
that ego's actual health status at this point was likely to 
be highly variable. Ego's "environmental fit" is largely 
the result of the willingness or ability of ego's network to 
accommodate to his/her needs. Thus, it was postulated that 
the objective severity of ego's health would vary given key 
conditions in ego's network. 

Measurement of health status can be determined based 
upon three different basic approaches: (1) the utilization 
of clinical records, (2) clinical examinations, and (3) 
household interviews. Due to ACLF regulations, the present 
population is required to have a medical record on file at 
their place of residence. Furthermore, it is mandated that 
this file is to include a record of a recent medical 



83 



examination (between 60 days prior to admission and 30 days 
after admission) of the resident. However, unless the exam- 
ination is performed after admission (and in this case must 
be reported on a standardized form) , the examination records 
will provide variable degrees of information on the resi- 
dent's health. Furthermore, even when the examination form 
is standardized the comparability of the medical evaluations 
is questionable due to observer variation, as no one physi- 
cian or nurse practitioner has been designated to perform 
all of the post ACLF examinations. Thus, this source of 
morbidity data was not considered as an indicator of the 
resident's health status. 

Three other indicators were utilized: a mental health 
measure which was derived from the mental functioning 
screening done at the onset of the resident interview, a 
self-assessment of health measure as determined from inter- 
views with ego and alter, and a self-care index which was 
derived from Katz's Activities of Daily Living (ADL) Ques- 
tionnaire (Katz, Ford, Moskowitz, Jackson, and Jaf fe, 1963) . 
This information was obtained from ego's primary care giver. 
As the Short Portable Mental Status Questionnaire has al- 
ready been described, only the latter indicators will now be 
discussed. 

Self-assessments of ego's health were addressed to the 
time of ego's move into the ACLF. Four responses were 



84 

possible: very good (0) , good (1), fair (2) , and poor (3). 
As self-assessments tend to be influenced by salient refer- 
ence groups (Ferraro, 1980; Fillenbaum, 1979), it was anti- 
cipated that controls for age and sex would be necessary to 
relate this measure to the more objective health indicators 
of mental capacity and self-care. 

The Katz scale (see Appendix C) is a cumulative ordinal 
scale that measures a person's level of functioning in six 
activities which people perform habitually and universally 
(bathing, dressing, toileting, transferring, continence, and 
feeding). Grading of the scale is as follows (Katz et al. 
1963:915) : 

A. independent in feeding, continence, 
transferring, going to toilet, dressing, 
and bathing; 

B. independent in all but one of these 
functions; 

C. independent in all but bathing and one 
additional function; 

D. independent in all but bathing, dressing, 
and one additional function; 

E. independent in all but bathing, dressing, 
going to toilet, and one additional function; 

F. independent in all but bathing, dressing, 
going to toilet, transferring, and one 
additional function; 

G. dependent in all six functions; and 

Other, dependent in at least two functions, 

but not classifiable as C, D, E, or F. 

Interestingly, Katz points out that while this order of 



85 

functional ability was determined through the evaluation of 
over 2 f 000 elderly, the pattern parallels "the recognized 
developmental pattern of child growth as well as the behav- 
ior of members of primitive societies" (1963:917). Further- 
more, as observed in the Katz study, the process of rehabil- 
itation and recovery of function is also consistent with the 
outlined ADL Scale. "Recovering patients passed through 
three stages: an early recovery of independence in feeding 
and continence, subsequent recovery of transfer and going to 
toilet, and, lastly, often after discharge, the recovery of 
complete independence in bathing and dressing" (1963:917). 
Of special interest is the observation by Katz and his 
associates that health is a process. Health is dynamic, not 
static. Thus, the researcher expected to observe some 
changes in the level of assessed health from Time 1 to 
Time 2 of data collection. 

Once ego's condition was perceived as a "problem," a 
response was in order. This is the third identified stage 
of the relocation process. In this study, the response was 
to relocate ego into an ACLF. The key variable here is who 
was responsible for referring ego to this living alterna- 
tive. This was measured by asking, "Who first suggested 
that moving into an ACLF might be a good idea?" Responses 
were identical to those for the labeling variable: "a 
relative" (0) , "a personal contact" (1) , "your doctor" (2) , 
"you determined it yourself" (3) , and "another health 



86 



professional" (4) . Responses were then aggregated into 
formal (2 and 4) and informal (0, 1, and 3) categories. 

The fifth dependent variable, the likelihood of being 
relocated from an ACLF to a home environment, was measured 
as a dichotomous variable with the location of ego at Time 2 
used to determine whether or not relocation out of the ACLF 
to a home environment had occurred. While this information 
was generally determined by the researcher after visiting 
ego, six of those residents who had left the ACLF were not 
able to be contacted. For these, either the former ACLF 
caregiver or the closest other was substituted as the infor- 
mation source. Ten responses were possible: living alone 
without any help (0) , living alone with the help of family 
and friends (1) , living alone with the help of formal agen- 
cies (2) , living alone with the help of family, friends, and 
formal agencies (3) , living with family/friends (4) , living 
with family/friends and being helped by formal agencies (5) , 
living ig home (6) , located in a hospital, but 
planning to return to an ACLF (7) , located in a hospital and 
planning to return home (8) , living in same ACLF (9) , and 
living in different ACLF (10) were aggregated into the 
dichotomous variable: returned to home environment (0, 1, 
2, 3, 4, 5, and 8), or remained in an institutional setting 
(6, 7, 9, and 10) . 



87 

Measurement of Independent Variables 
Three primary independent variables were identified: 
(1) the connectedness of ego's primary ties, (2) the direc- 
tion of ego's primary ties, and (3) the intensity of ego's 
primary ties. As these are all network variables, ego was 
considered the primary informant, with alter substitutes 
used as necessary. 

Two different measures of network connectedness were 
computed — density and degree. Once again, measures were 
computed for both ego's personal network (defined as those 
family plus nonresident alters meeting minimal inclusion 
criteria) and for kin and nonresident subfields. 

As was outlined in the theoretical chapter of this 
dissertation, density is the proportion of the theoretically 
possible direct links that exist in a particular network 
(Barnes, 1969) . Mathematically this measure was formulated 
as 

D = 100 x Na 

1/2 N (N - 1) 

where D refers to density, Na refers to the number of actual 
relations in a network, N refers to the number of persons 
involved, and 1/2 N x (N - 1) refers to the number of theo- 
retically possible relations in a particular network 
(Neimeijer, 1973:46) . 

Degree is the average number of relations members of a 
network have with other members. This is operationalized by 



88 



the following mathematical formula: 



d = 2 x Na 

N 



where Na refers to the number of actual relations and N 
refers to the number of persons involved (Neimeijer, 
1973:47) . 

Measuring the degree of a network is especially useful 
when one is comparing the connectivity of networks of dis- 
parate sizes as it takes into account the size dimension of 
ego's network. And, while a large network size variance 
such as that which was discussed by Cubitt (1973) was not 
anticipated in this population, it was not known if a theo- 
retically significant size difference would be present. 
Thus, analyzing the effects of both of these variables on 
ACLF placement gave a more complete picture of the relation- 
ship between network connectivity and this process. 

It was anticipated that some residents would either be 
without any personal network or have such small networks 
that their total network size and/or their subnetwork size 
would have less than two members in addition to themselves. 
As density as well as degree measures are only meaningful if 
network size is greater than or equal to three, measurement 
of these variables for these subjects is not possible. 
However, examination of this "network deficient" group is of 
interest in and of itself. Thus a demographic and health 



89 



profile of those with deficient total, relative, and non- 
relative network was included in the analysis, as was a com- 
parison of how this group "looks" and how they orchestrated 
their move into the ACLF in comparison to the nondeficient 
group. 

In adhering to this strategy, the interrelatedness 
between density and degree was not neglected. As outlined 
by Neimeijer (1973) , density can be substituted into the 
formula for measuring density: 



D = 1QQ x d 

(N - 1) 



where D refers to density, d refers to degree, and N refers 
to the number of persons in the network being analyzed 
(1973:48). As can be seen, density varies directly with 
degree, but inversely with network size. Thus, the effects 
of these variables on the dependent variables were analyzed 
separately, minimizing the problems of multicollinearity. 

Data on the number of actual links (Na) were obtained 
by listing each member of ego's primary network on a blank 
sheet of paper. The researcher then assisted the respondent 
in connecting each of these members who were currently in 
regular contact with each other. In this case network size 
(N) and the number of actual links (Na) included all network 
members and linkages identified by either ego or alter (see 
Appendix D, Number 17) . 



90 



The second identified independent variable was tie 
directedness. Of interest was the variable interactional 
effect of unidirectional verses reciprocated links. As was 
pointed out in the theory chapter of this dissertation, the 
notion of tie reciprocity is broader than that of tie sym- 
metry, implying equivalency in social exchanges rather than 
indicating that the exchanges be roughly identical. Thus, a 
tie was considered reciprocated if there was a link flowing 
from ego for each link flowing to ego. In this regard, the 
existence of material links (i.e., personal assistance, 
money or loans, or other gifts) to and/or from ego was 
assessed. "Objective" network reciprocity scores were then 
determined as per Sokolovsky et al. (197 8) by computing the 
proportion of ego's total links that were reciprocated. 
Consistent with the previously outlined methodology, both 
subfield and total personal field scores were computed. 

Along these same lines it is also important to recall 
that the perception of tie equivalency by the involved 
parties is also cited. Thus, consistent with the approach 
used by Ward, Sherman, and LaGory (1984), this "objective" 
measure was complimented by questioning the respondent, 
"When you consider everything that you share with (substi- 
tute name of network member) i.e., personal assistance, 
gifts, financial assistance and love and companionship, 
would you consider that over the long run you get about as 



91 

much from ( ) as you give to ( )?" Subjective network 
reciprocity measures were then determined by computing the 
proportion of ego's total relationships that were perceived 
to be reciprocated. Once again, both subfield and total 
personal field scores were computed. 

The third identified independent variable in this study 
is tie intensity. While a theoretical understanding of 
intensity has been demonstrated in the literature (Epstein, 
1961; Granovetter, 1973; Mitchell, 1969; Wheeldon, 1969), 
validated empirical indicators of this concept are somewhat 
elusive (Marsden and Campbell, 1984) . As intensity is a 
multidimensioned construct involving components of time 
spent (frequency of contact and duration) , depth (emotional 
intensity and intimacy) , and reciprocity as Granovetter 
theorized (1973) and Marsden and Campbell (1984) attempted 
to empirically verify, its measurement should take into 
account each of these dimensions. This was the strategy 
used by the researcher for measuring the intensity of the 
link between ego and his/her "closest other." An attempt 
was made to maximize the "fit" between theory and reality, 
by operationalizing each of its dimensions. Intensity 
was determined to be indicated by 

1. the degree of emotional bondedness between 
ego and alter (as perceived by ego) ; 

2. the degree of emotional bondedness between 
ego and alter (as perceived by alter) ; 

3. the duration of the relationship; 



92 



4. the number of reciprocal material ties 
between ego and alter; and 

5. the frequency of visiting contact between 
ego and alter. 

A similar approach to operationalizing this construct 
was utilized in a recent work by Lin, Woelfel, and Light 
(1985) . Duration, frequency, intimacy and emotional support 
were also included as construct dimensions. However, they 
operationalized intimacy and emotional support via a series 
of five questions, rather than through Snow and Crapo's 
Emotional Bondedness Scale (1982) . An additional important 
difference in their methodology was that alter' s perception 
of their relationship was not included. 

In this study the subcomponents were quantified on a 
three-point scale. As the Emotional Bondedness Scale meas- 
ures both intimacy and closeness, its weight was doubled. 
Thus, total scores for the five-dimensioned scale could 
range from 7 to 21. 

Ordering of these subcomponent responses into high, 
medium, and low categories was not determined until after 
the initial data were collected to maximize the fit between 
the theoretical and empirical meanings of intensity. The 
frequency distributions of the elements around their median 
revealed theoretically meaningful high, medium, and low 
categories for all but the duration dimension of intensity. 



93 

Due to the age of the respondents, and the large per- 
centage of respondents that mentioned a relative as his/her 
"closest other," there was typically a very high duration of 
the relationship between ego and alter. The median duration 
was 40 years, with an upper quartile beginning at 50 years, 
and a lower quartile beginning at 21 years. 

Furthermore, when duration was regressed on ego's age 
and kinship with the significant other, highly significant 
direct relationships were demonstrated (p < .001) . Thus, in 
effect, for this population duration indicated the age of 
the respondent, and hence, the age of his/her closest other, 
along with ego's kinship with alter, rather than the inten- 
sity of the relationship. Duration was, therefore, deleted 
from the subcomponents of the intensity construct, reducing 
the potential range of scores to from 6 to 18. 

The contaminating effects of age and kinship on dur- 
ation were also recognized in the work of Marsden and 
Campbell (1984) . Additionally, they found that frequency of 
contact via visiting was complicated by neighboring. Net of 
strength, neighbors tended to see each other more often than 
non-neighbors. 

This same complication appeared in this study, only in 
a slightly different form. Frequency visiting was skewed to 
the right due to the high percentage of new residents who 
had lived with their closest other prior to their move into 
the ACLF, and hence visited him/her daily. However, as 



94 



visiting is a crucial component of a relationship for the 
noninstitutionalized frail elderly, facilitating both ma- 
terial and nonmaterial exchanges, and as contacts visiting 
was more discriminating than contacts speaking in defining 
the intensity of the relationship between ego and alter, it 
was determined that this "time spent" component of intensity 
remain in the scale. 

To accommodate to the data, the upper quartile of the 
visiting dimension was defined to include the 75% percentile 
and above. This had the effect of limiting the high cate- 
gory to daily contact (8). The middle quartile was then 
measured as those scores between but not including those 
ranked 25% to those ranked 75%, which translates to contact 
weekly or several times a week. Low contact by ego's clos- 
est other, thus, was considered as contact on a less than 
weekly basis. 

The other subcomponents' medium scores all included 
those ranked 25% to those ranked 75% on that item. In terms 
of ego's perceived bondedness this translates to a score of 
36 indicating high, a score of 30-35 indicating medium, and 
a score of less than 30 indicating a low intensity relation- 
ship. Interestingly, bondedness of alter to ego was ranked 
quite a bit lower, with scores above 33 considered high, 
scores between and including 24 and 33 considered medium and 
scores of less than 24 considered to indicate a low 



95 

intensity relationship. In terms of reciprocity, if all the 
three possible links were reciprocated this was scored high. 
If one or two links were reciprocated this was scored 
medium, and if no links were reciprocated this was scored 
low. 

In terms of ego's network, network emotional bonded- 
ness, a partial component of intensity, was used as the 
variable indicator. Measurement was accomplished by asking 
the respondent the 12 items in Snow and Crapo's (1982) scale 
in regards to ego's relationship with each network member. 
Responses were then totaled for both ego's subnetworks and 
total primary network and divided by network size to obtain 
a mean. This strategy was chosen due to the complexity of 
obtaining a composite network measure for each of these 
subcomponents and the demonstrated superiority of the mea- 
sure of the emotional intensity of a tie over any other 
single indicator available to us (Marsden and Campbell, 
1984) . 

Controls were added for sex, race, and socioeconomic 
status as they have been both theorized and demonstrated to 
have an effect on health-related behavior (Freidson 1970; 
Gove and Howell, 1974; Horwitz, 1977; Verbrugge, 1985). 
Each of these was dichotomously coded with males, whites, 
and private payers coded and females, nonwhites, and 
private residents coded 1. 



96 



The "nonconventional" indicator of socioeconomic status 
was used as it was determined from past participant observa- 
tion at ACLFs by the researcher to be the most meaningful 
way that the residents discriminate between those "who have" 
and those "who have not." Additionally, this approach pro- 
vides potentially useful information to the state agencies 
responsible for assuming the financial burden of caring for 
those "who have not." As the data indicated that alter was 
the one primarily responsible for orchestrating ego's move 
into the ACLF, alter was considered the primary information 
source on ego's method of financing ACLF care with ego 
substitutes used as necessary. 

Ego's health at Time 2 and place of residence on 
follow-up were also important controls when tie duration was 
being analyzed. Variable measurement was identical to the 
strategy used when health and location are of interest as 
independent variables. 



CHAPTER SIX 
THE PARTICIPANTS: THE NEW RESIDENTS 



Presenting Demographic and Health Profile 
While there was considerable variation among the new 
residents in terms of their functional ability and mental 
capacity, a typical demographic profile did emerge. Of the 
81 residents included in the study, the majority were unmar- 
ried (87.6%), white (85.%), female (69.1%), aged 80 years 
and older (54.3%), and were either paying for their care 
themselves (61.7%) or with the help of their families 
(18.5%) . In terms of education, however, no typical pattern 
was presented: 37.5% had less than a high school education; 
32% had at least some high school education; and 30% had 
more than a high school education. 

This picture is similar to the one described in the 
1985 report by Florida's Office of Evaluation and Management 
Review which randomly sampled from all ACLF residents 
throughout the state. Of those 60 and older in that sample, 
the majority were female (73%) , white (94%) , and unmarried 
(81%). The average age of all the residents (including 
those under 60) was 79, with 91% of them over age 60. Four- 
teen percent of that total sample's care (including those 



97 



98 

under 60) was state-financed. Thus this select, new group 
of ACLF residents in central Florida contains slightly more 
males, nonwhites, nonmarrieds, and state-financed residents 
than the statewide resident population. 

As was hypothesized, the residents' presenting health 
status as measured by Katz's functional, self-care index and 
as charted by Pfeiffer's Short Portable Mental Status Ques- 
tionnaire was highly variable. There was no typical pre- 
senting physical or mental level of health in the new resi- 
dents. While 37% of the sample needed no assistance with any 
of the six activities of daily living assessed in the scale, 
34.6% needed assistance in two or more functions. In fact 
3.7% of the sample were dependent in all six assessed areas. 
A more complete picture of their presenting self-care abili- 
ties is illustrated in Table 6-1. 

The resident's initial level of mental functioning was 
also highly variable. While approximately two-thirds 
(67.9%) of the sample were determined to be mentally com- 
petent, i.e., they demonstrated either intact functioning or 
only mild impairment, the other one-third were either moder- 
ately or severely impaired, and hence deemed mentally incom- 
petent. 

To check the validity of these measures, self- 
perceptions of ego's health were regressed on each of the 
objective measures with controls added for sex and age. Ego 



99 
was considered the primary informant for these data, with 



Table 6-1. New resident presenting self-care ability, as 
determined by Katz's Activities of Daily 
Living Index (N = 81) 



Self-Care Ability Frequency Percentage 



Total independence 

Independence in all but one 
function 

Independence in all but bathing 
and one additional function 

Independence in all but bathing, 
dressing, and one additional 
function 4 4.94 

Independent in all but bathing, 
dressing, going to toilet, and 
one additional function 5 6.17 

Independent in all but bathing, 
dressing, going to toilet, 
transferring, and one 
additional function 4 4.94 

Dependent in all six functions 3 3.70 



30 


37.04 


23 


28.40 


12 


14.82 



100 

alter substitutes used as necessary (n = 28) . Both 
objective measures were found to be significantly related to 
ego's perceived health status in the predicted direction 
with a p < .0005 (physical health) and a p < .01 (mental 
health) . 

Morphological Network Characteristics 
Appendix H presents the means and standard deviations 
of the morphological characteristics of the new resident's 
networks. Data were collected on the morphological vari- 
ables range, density and degree for both ego's total adult 
primary network and primary relative and nonrelative sub- 
fields. As noted earlier, ego was considered the key infor- 
mant for this information when assessed to be mentally 
competent and physically able to complete the survey. As 26 
residents were incompetent at Time 1 and 4 were physically 
limited, alter 's responses were then substituted for approx- 
imately 30 surveys (two respondents with physical limi- 
tations were able to partially complete the survey, and 
their responses were used as available) . To determine the 
appropriateness of this approach, paired t-tests were done 
on data from alter with matching ego responses. No signifi- 
cant differences emerged between the two sources on any of 
the network variables, substantiating the validity of this 
methodology. 



101 

Range 

Range refers to the size of the delimited portion of 
ego's network. As stated earlier, after identifying all 
those adult relatives and "close" others ego was in regular 
contact with during the past year, this measure was refined 
by the existence of two criteria — contact with ego at least 
several times during the last year, and the presence of 
either a material link or a nonmaterial link (defined via 
Snow and Crapo's Emotional Bondedness Scale) between ego and 
alter. 

The mean size of this total primary network of ego was 
7.4, with subnetwork means of 2.8 for the nonrelative sector 
and 4.7 for the relative sector. However, the wide range in 
network size should not be overlooked. For ego's total 
primary network, approximately 16% of the respondents had 
networks greater than 11.5 and 16% had less than 3.3 network 
members. Variations in ego's relative network were such 
that approximately 16% of the ego's relative networks were 
larger than 7.5 and 16% were smaller than 1.7, and 16% of 
the residents nonrelative primary networks had more than 5.6 
and 16% had no members in this sector at all. 

Meaningful comparisons of these results with other 
findings in the literature require at least comparable 
network delimitation methods. For the elderly, the closest 
measure that this researcher could find was in Cantor's 
(1979) study of the elderly 's informal support networks. The 



102 



mean numbers of functional friends (seen at least monthly or 
in phone contact at least weekly) and functional neighbors 
(known well and interacting with in one or more instrumental 
ways) were reported. As most functional friends were found 
to be neighbors, this latter category can be roughly under- 
stood to subsume that of friends and may be similar in 
meaning to this study's category of nonrelative primary 
group members. 

Cantor found these low-income , noninstitutionalized New 
Yorkers to have a mean of .66 functional friends and 2.1 
functional neighbors. While this latter number is slightly 
less than this researcher's finding of a mean of 2.8 non- 
relative primary group members, as Cantor's sector includes 
most, but not all of the respondents' friends, our findings 
are interestingly close. 

Wellman's 1981 study (coincidently also of New Yorkers) 
reports some comparable network data on a younger adult 
population. Although, as with Cantor's work, no attempt was 
made to quantify such definitions as "close" or friendship, 
Wellman delineated active network sectors of intimates (all 
ties defined as close) , sociables (all ties whose company is 
enjoyed and whose absence would be missed), and supportives 
(ties who give at least one type of supportive aid) . The 
latter category seems to most closely reflect the total 
personal network as defined in this study. The reported 



103 

mean size of the supportive sector was 11, which is approxi- 
mately 4 greater than the average personal network size of 
this sample. Given the age difference of the sample this is 
a reasonable difference. The more restrictive categories of 
intimates and sociables had means of 5 and 8, respectively. 

Density and Degree 

In terms of the density of ego's primary network, most 
network members were in fairly regular contact with each 
other. This finding is consistent both with Granovetter ' s 
(1973, 1981) theory that one's network of close ties are 
more likely to be bound to each other than one's network of 
weak ties and with other research on the structure of in- 
timate networks (Cubitt, 1973; Hammer et al., 1978; 
Kapferer, 196 9) . However, to the knowledge of this re- 
searcher this is the only density data to date on the net- 
works of the vulnerable elderly. 

Not surprisingly, the relative subsector was most 
tightly bound. The mean density was 89.0%, indicating that 
on average 89% of the members of ego's relative network are 
in fairly regular contact with each other. Nonrelative 
sectors were also quite closely bound, with an average 
density of 75.1%. Again, this is consistent with 
Granovetter 's theory. "If strong ties connect A to B and A 
to C, both C and B, being similar to A are probably similar 
to each other, increasing the likelihood of a friendship 



104 

once they have met" (Granovetter, 1973:1362). As the mean 
duration of ego's friendship ties was 18.4 years, C and B 
have had plenty of time to become acquainted with each 
other. 

There was a higher probability of any two members in 
the subsectors being linked than in the total network. 
Thus, while ego's subsectors were quite dense, the density 
of his/her total network was a relatively low 65.8%. Yet, 
this finding is still quite high and should not be taken to 
indicate that these total primary networks are not intercon- 
nected. 

As noted earlier, another way to measure a network's 
interpersonal mesh is by calculating the degree or mean 
number of relations network members have with each other. 
Unlike the density figure, as the size of the network in- 
creases, the potential degree will increase. Therefore, if 
two networks have relatively the same densities, the larger 
network will have the higher degree. In this case, the 
larger the network, the larger was the degree. The mean 
number of relationships between any one member and the other 
network members was 5.0 for the total primary network, 4.6 
for the relative network subsector, and 3.7 for the nonrela- 
tive subsector. 



105 

Interactional Network Characteristics 

Tie Content and Directedness 

Appendix H also presents the means and standard devia- 
tions of the interactional characteristics of the new resi- 
dents 1 networks. Data were collected on the interactional 
characteristics content, directedness, duration and fre- 
quency for both ego's total adult primary network and rela- 
tive and nonrelative primary subfields. In regards to con- 
tent, information on both material and nonmaterial links 
between network ties was compiled. Material links were 
defined as the transfer of personal assistance, gifts, or 
financial assistance from either ego to alter or from alter 
to ego. 

Interestingly, at the time of the new resident's move 
into the ACLF ego was connected to his/her network members 
by a fairly large number of material linkages. The mean 
number of linkages in the total network was 9.7, in the 
relative sector, 7.2, and in the nonrelative sector, 2.5. 
It is not surprising that relatives have more material links 
to ego than nonrelatives. However, the finding that, on 
average, 2.5 material links exist between nonrelative net- 
work members and ego lends further support to Cantor's 
(1979) finding of the importance of friends and neighbors as 
an informal support system for the elderly. 

When the additional criterion of material linkages is 
demanded for alter to be included in ego's network, the mean 



106 



size drops. In ego's total network, on average, 5.6 ties 
had at least one material link with ego. In the relative 
subsector, a mean of 3.9 ties had at least one material 
link, and in the nonrelative subsector there was a mean of 
1.8 ties with at least one material link with ego. Thus, 
of those people ego felt close to and was in fairly regular 
contact with, an average of 20% were not materially linked 
to him/her. Of those with nonrelative subnetworks (N = 63) 
nearly 40% of this sector were not tied to ego by at least 
one material link. And, of those with relative subnetworks 
(N = 7 8) , an average of 13% of this sector were not tied to 
ego by at least one material link. 

Three different types of links can connect ego and any 
given network member: reciprocated, instrumental, and de- 
pendent. Data were collected on each of these links for 
both ego's total primary network and relative and nonrela- 
tive subsectors. In all three networks the greatest mean 
number of links was reciprocated: 5.2 (total), 4.1 (rela- 
tive), and 1.3 (nonrelative). Dependent links were next 
most frequent in all networks with mean numbers of 3.4 
(total), 2.4 (relative), and 1.0 (nonrelative). And while 
instrumental ties were rare, they were not nonexistent: .8 
(total), .8 (relative), and .2 (nonrelative). The high 
number of reciprocated links is due, at least in part, to 
the inclusion of the "carry over dimension" of reciprocity 



107 

in the data on personal assistance directed from ego to 
alter. Past assistance from ego to alter was considered as 
a material link. Thus, if ego was currently receiving 
material aid from a network member in one of the three 
assessed areas, and ego had rendered personal assistance to 
that person in the past, this linkage would be considered 
reciprocated. 

These numbers can also be translated to indicate the 
mean percentage of the total links in each network that are 
of each pattern. Once again the majority of the links are 
reciprocated: an average of 52.3% of the links in the total 
network, 50.0% in the nonrelative network, and 56.5% in the 
relative subsector. Yet, ego has, on average, a large 
percentage of dependent links: 38.% of the total links are 
dependent, 46.4% of the nonrelative links, and 33.7% of the 
relative links are dependent. 

Possibly the most interesting finding that becomes more 
apparent when the data are viewed from this perspective is 
the percentage of linkages that were instrumental. In ego's 
total network an average of 8.2% of the links are instru- 
mental. In the subfields, 13.3% of the nonrelative and 9.8% 
of the relative links are unidirectional from ego to alter. 
Again, it should be noted that a good portion of these links 
are probably due to past personal assistance by ego to alter 
that is not currently being "repaid" in any material manner 
by alter. 



108 

While the researcher was able to locate no study that 
explicitly examined the directionality of material links in 
the networks of vulnerable elderly, several tangential find- 
ings might help put these results into perspective. Of 
these, Wentowski's study on reciprocity and the coping 
strategies of nonistitutionalized elderly who still had a 
"fair degree of control over their lifestyles" (Wentowski, 
1981:602) is probably the most similar in content and pur- 
pose to the present work. This was a qualitative work, 
combining depth interviews and participant observation of 50 
older adults. She, too, claims that the norm of reciprocity 
is the basis of exchange relationships for her sample. 
However, the only data reported (aside from that contained 
in three case studies and occasional quotes) are the 
percentages of informants reporting kin and non-kin helpers. 
Only those kin identified as relatives by marriage were not 
commonly involved in helping relationships with the respon- 
dent. While this indicates a large percentage of ego's 
network had at least one material link with ego it does not 
substantiate her claim of reciprocity-governed exchange 
relationships. 

Wellman (1981) examined linkage direction amongst his 
sample of East New Yorkers. However, as he reported per- 
centages of each pattern within each category of supportive 
link (i.e., family advice, minor services, major amounts of 
money) his analysis is closer in meaning to symmetry than to 



109 



reciprocity. Thus, it is not surprising that the percentage 
of symmetric links between ego and alter is considerably 
less than the percentage of reciprocated links reported in 
this study. For Wellman, symmetry was the exception rather 
than the norm, especially in the case of major resources. 

Sokolovsky et al. (1978) also reported data on tie 
directionality in their study on residents of single room 
occupancy hotels. As in this study, they too, looked at 
directionality from a reciprocity perspective. While reci- 
procity predominated in those without any psychosis both in 
relationships within and outside of the hotel, for those 
with either active schizophrenia, or a history of psychosis, 
reciprocity was rare within the hotel, and only slightly 
more prevalent than dependency with those outside hotel 
relationships. Thus, dependency was much more common in 
this group than those without psychotic symptoms. 

Finally, Cantor (1979) focused on understanding the 
nature of dependency among low-income New York elderly. She 
reported (as does this study) that in terms of material 
tasks, kin formed the predominant links to ego. However, in 
terms of affective assistance (nonmaterial links) , the pro- 
portion of links between relatives and friends was fairly 
evenly split. This may be explained by the norm of reci- 
procity. Material links are more likely to be reciprocated 
with relatives than with nonrelatives (note the higher 



110 

dependency ratio in this study in the nonrelative vs. rela- 
tive sectors) , whereas, nonmaterial links between nonrela- 
tive personal network members are probably less likely to be 
dependent than those in the relative subsector. 

In fact, in this study nonmaterial network linkages 
were stronger between ego and the nonrelative sector (mean 
bondedness was 33.1) than between ego and the relative 
sector (mean bondedness was 31.0). The mean bondedness 
between ego and his/her total primary network was 32.1. 
Although the emotional bondedness measure used does not 
exclusively indicate reciprocity, it does take it into 
account. 

The measure of ego's perceived tie equivalency took 
into account both material and nonmaterial linkages between 
ego and alter. Thus, the higher proportion of "balanced" 
relationships" reported verses the computed proportion of 
reciprocated material links may in part be explained by 
ego's incorporation of the nonmaterial component into this 
subjective measure. On average 73% of the total ties, 67% 
of the relative ties, and 69% of the nonrelative ties were 
perceived as balanced. However, given that the norm of 
reciprocity actually exists, and hence, that relatives 
"should" be repaying ego for help rendered in the past, 
these higher proportions may also reflect ego's desire to 
present a normative, nondeviant picture of his/her network 
relations. 



Ill 



Frequency and Duration 

Frequency and duration were also computed in terms of 
network means. Summary statistics are presented in Table 
6-2. Comparisons across network groups indicate that there 
was a higher reported frequency of visiting and speaking 
contact and a lower frequency of written contact between ego 
and his/her nonrelative sector than between ego and his/her 
relative sector at Time 1. These results are compatible 
with those of Chappell (1983) r who notes that in her study 
of over 400 elderly Canadians, face-to-face contact with 
close friends is more frequent than with relatives living 
outside the household. In tandem, this suggests that while 
at least part of ego's relative network is most likely 
geographically dispersed, nonrelative network members are 
more likely to be neighborhood bound. Similar results were 
reported by Cantor (1979) . 

Comparisons across type of contact indicate that 
speaking was the most common means of contact in both rela- 
tive and nonrelative sectors. But, given that this category 
included telephone as well as face-to-face conversations the 
difference between speaking and visiting was interestingly 
small. This was especially so in the nonrelative sector. 
It seems that most of these people are primarily in face-to- 
face contact with ego. Writing was quite rare in both 
sectors, but once again this was especially so in the 



112 



Table 6-2. 


Mean contact frequency with ne 
by type of contact and type of 


bwork members 
network 










Network 






Contact 


Total 
(N = 80) 




Relative 
(N = 78) 




Nonrelative 
(N = 63) 


Visiting 
Speaking 
Writing 




4.23 
5.19 
1.06 




3.70 
4.95 
1.30 




4.83 

5.55 
.65 



113 

nonrelative field, again lending support to Cantor's notion 
of the neighborhood boundedness of ego's nonrelative per- 
sonal network. 

Given that many of these vulnerable elderly have a 
diminished mental capacity, the predominance of contact by 
visiting may be due in part to the fact that visual cues may 
be necessary to maximize meaningful communication between 
ego and alter. Furthermore, while these results suggest 
that ego's nonrelative sector is in relatively close prox- 
imity to ego, as the mean duration of ego's nonrelative ties 
was 18.4 years, and approximately 16% of those ties were 
known longer than 32.2 years, and given the mobility of our 
society, it is unlikely that these ties can be completely 
understood by limiting one's analysis to local contacts. 

In terms of the relationship with ego's closest other, 
the duration varied with ego's age (p < .001) and kinship 
with ego (p < .001). The mean duration of ego's relation- 
ship with close nonrelative others was 7.2 years, while with 
close relative others the mean duration was 46.7 years, 
suggesting that the length of the relationship with ego's 
close relatives was limited only by the age of ego and the 
relative. 

In conclusion, upon entering into an ACLF the average 
resident is still surrounded by five relatives and three 
nonrelatives to whom he/she is highly emotionally bonded. 
While these relatives and nonrelatives are likely to be in 



114 



contact with each other, the density of these combined 
sectors is, on average, quite a bit lower. 

The majority of these close others are still materially 
bonded to ego, with the highest percentage of these links 
being reciprocated. While relatives have a higher number of 
material links to ego, nonrelatives are more highly emotion- 
ally bonded to ego, and are in more frequent visiting and 
speaking contact with him/her. Thus, the functions these 
two sectors provide to ego seem to compliment each other. 



CHAPTER SEVEN 
BETWEEN-GROUP NETWORK DIFFERENCES 



In addition to analyzing the demographic and health 
profile of the new residents as a whole, this analysis was 
taken one step further to examine whether differences in 
network characteristics could be explained by the social 
structure of ego's world and/or ego's presenting health 
status. An analysis of variance was done to test for sig- 
nificant between-group network variation. 

The structural variables sex, race, and socioeconomic 
status as well as indicators of ego's mental and physical 
health status were the group defining variables. Each of 
the structural variables were dichotomously grouped — male, 
female; white, nonwhite; and private payer, state-financed. 
The same approach was used for the health indicators. Men- 
tal health was grouped by assessed competence level, with 
labels of competence or incompetence determined according to 
Pfeiffer's Short Portable Mental Status Questionnaire 
(1975). Physical health was grouped according to ego's 
self-care capacity as determined by Katz's Activity of Daily 
Living scale. If ego could perform all six activities of 
daily living unassisted, he/she was considered nonfrail, 
with those who needed assistance in one or more areas 
considered frail. 



115 



116 

The network characteristics explored were size (of both 
the personal network as defined in this study and that 
portion of that network which are also materially linked to 
ego) ; density and degree; mean network emotional bondedness 
to ego; the proportion of network links that are reciprocal, 
dependent, and instrumental; the proportion of ties per- 
ceived as balanced; and the mean frequency of visiting, 
speaking, and writing contact between ego and his/her per- 
sonal network. 

The characteristics of both ego's total personal net- 
work and relative and nonrelative subsectors were analyzed. 
However, as the network definition became more restrictive, 
the sample size became smaller. This made it harder to 
reject the null hypothesis of no group differences, and may 
at least in part account for the sparsity of significant 
between group differences in regard to ego's nonrelative 
subsector. For instance, only 46 respondents had a large 
enough nonrelative network to analyze group differences in 
density and degree (a minimum of three members were needed) . 
Similarly, only 63 respondents had a large enough nonrela- 
tive subsector to analyze between group differences in net- 
work emotional bondedness to ego and network contact pat- 
terns with ego. And, only 51 respondents had at least one 
material link in their nonrelative subsector. 

A multiple analysis of variance was performed to allow 
the researcher to assess the effects of each these 



117 



independent variables on the outlined network character- 
istics while controlling for the effects of the other inde- 
pendent variables. However, as each of the health indica- 
tors are highly correlated, the problems of multicollin- 
earity were avoided by analyzing them separately. 

Differences by Sex 

Controlling for ego's race, socioeconomic status, and 
health (both physical and mental) , only three of the identi- 
fied network characteristics were explained by sex. There 
was a significant difference between the sexes in network 
density, size and in the frequency of contact with ego and 
network members. There was no significant difference be- 
tween the sexes in terms of their total personal network 
size (when defined with the additional criterion of at least 
one material linkage with ego) , network bondedness to ego, 
frequency of network writing, or either objective or subjec- 
tive network tie directionality (see Appendix I, Table 1-1) . 

In terms of network structure, while the average number 
of relations between network members (degree) was not signi- 
ficantly different between males and females regardless of 
whether one looked at ego's total personal network or either 
of the identified subsectors, males had a higher total 
network density than females (p < .05). Thus, there was a 
higher proportion of the theoretically possible links in the 
total personal networks of males than of females. 



118 



However, when the relative and nonrelative subsectors 
were analyzed separately, this relationship disappeared. 
There was no significant difference by sex. This means that 
among only ego's relatives, and among only ego's close 
nonrelative ties there was no difference between males and 
females in the proportion of links actualized. But, when 
these important groups were combined the internetwork link- 
ages were greater for men. If density is indeed a support- 
ive resource, this may be a critical between-sex network 
difference. 

Positing an explanation for this relationship in the 
differential marital states of the sample's males and fe- 
males, a control for this variable was added. No spurious 
relationship was revealed. Marital status was not signifi- 
cantly related to ego's total personal network density, and 
the association between sex and network density remained 
significant (p < .01) . 

The size of ego's network was only different by sex 
when analyzing ego's total personal network controlling for 
ego's physical health (p < .05). However, there was a 
consistent tendency for the networks of females to be larger 
than that of males. 

In terms of the interactional variable, contact fre- 
quency, while there was no significant difference in the 
mean frequency of written communication between ego and 



119 

his/her network by sex, males and females did have signifi- 
cantly different visiting and verbal network interactional 
patterns. Men had, on average, more frequent visits with 
the members of their total personal network than did females 
(p < .05). This relationship remained when only ego's rela- 
tive subsector was considered (p < .001) , but was not signi- 
ficant when only ego's nonrelative subsector was considered. 
Men also were in more frequent verbal communication with 
their network, but this relationship was significant for 
ego's relative subsector only (p < .01). 

Once again, it was posited that this association was 
due to the differential marital states of older males and 
females. To this end controls were then added for marital 
status. No spurious relationship was revealed. Marital 
status was not significantly related to total network mean 
frequency visiting and the association between sex and 
visiting remained significant (p < .05) . 

The results of recent research on the relationship of 
sex to the primary network patterns of the elderly is incon- 
clusive, with some authors reporting a decreased quantity or 
quality of primary networks among elderly males than females 
(Fisher and Oliker, 1979; Strain and Chappell, 1982), others 
reporting no network differences by sex (Bogatta and Foss, 
1979) , and still other authors finding, as did this study, 
an increased quantity or quality of primary networks among 
elderly males (Ferarro and Barresi, 1982) . However, none of 



120 



these works focused on ego's relationship with his/her pri- 
mary network as a unit, thus overlooking such concepts as 
density and degree in their analysis. Rather, they focused 
on the interaction network characteristics of intensity and 
contact frequency between ego and specific ties. This dis- 
sertation, then, gives a new perspective to the research on 
social networks and the elderly. 

Differences by Race 

Controlling for ego's sex, socioeconomic status, and 
health (both physical and mental) , five network variables 
were associated with ego's race: density, degree, bondedness 
to ego, frequency of contact, and perceived tie reciprocity. 
There was no significant difference between whites and non- 
whites in terms of the size of ego's personal network; the 
size of the subset of that network that was also materially 
linked to ego, or in the objectively determined direction of 
their network ties (see Appendix I, Table 1-2). 

Both a higher percentage of possible links were actual- 
ized (density) in the total personal networks of nonwhite 
new residents (p < .05) and network members had a higher 
average number of intranetwork linkages, or degree 
(p < .05). When ego's subnetworks were analyzed, a slightly 
different picture emerged. Only the density of the relative 
subsector (p < .05) and only the degree of the nonrelative 
subsector (p < .05) were significantly higher for nonwhites. 



121 



Yet, the trends revealed for the total network remained. 
Thus, the network structure of nonwhites was "glued" to- 
gether more tightly, facilitating greater support for ego, 
the possibility of greater normative pressure for this sup- 
port, and a greater potential for the network of nonwhites 
to maintain their relationship with ego despite ego's move. 

The "strength of the glue" may be a causal factor in 
the significantly higher network emotional bondedness to ego 
for nonwhites than for whites. This relationship was sig- 
nificant for the total primary network (p < .001) and for 
the relative (p < .005) and nonrelative subsectors 
(p < .05) . Another explanation for the apparently higher 
degree of emotional bondedness of nonwhites to their network 
may be found in the work of Creecy and Wright (197 9) . While 
the researcher attempted to minimize any perceptual differ- 
ences related to friendship by different individuals or 
social groups by using the Emotional Bondedness Question- 
naire (Snow and Crapo, 1982), it is possible that these 
potential differences carried over to the way ego inter- 
preted the elements of the researcher's questions. This 
could have resulted in a tendency for nonwhites to answer 
more favorably in regard to their primary network relation- 
ships. 

Whites and nonwhites also differed in the manner in 
which they stayed in contact with each other. While no 



122 

significant differences by race emerged in ego's contact 
with his/her nonrelative subsector, if ego was nonwhite, ego 
was more likely to be in both speaking (p < .01) and vis- 
iting (p < .05) contact with his/her relatives and in 
speaking contact with his/her total primary network 
(p < .05) and less likely to be in written contact (p < .05) 
with his/her total primary network and relative subsectors. 
As this relationship was revealed controlling for the socio- 
economic status of ego, any explanation must be found else- 
where. Possibly, nonwhites were in closer proximity to 
their network, facilitating more network visiting. However, 
if this is so, one wonders why the geographical dispersion 
of ego's network varies between nonwhites and whites. Fur- 
thermore, geographical dispersion would not totally account 
for the differences in verbal and written contact between 
whites and nonwhites. An educational difference between the 
two groups may be partially responsible, with nonwhites 
having less education, and hence being less comfortable with 
written communication. Another explanation would be cul- 
tural. As one nonwhite respondent said, "We don't like to 
write. ... We feel it is so much more personal to call." 

Finally, although, the objective measure of tie dir- 
ectionality revealed no significant difference between 
whites and nonwhites, nonwhites were significantly more 
likely to perceive that the relationship with their primary 
network members was balanced (p < .005) . Although the 



123 



reason for finding a significant relationship with race and 
perceived balance can only be speculative, two plausible 
explanations are offered. First, this finding may be due to 
the more inclusive nature of the perceived measure. While 
the objective measure addressed only material links, the 
perceived measure included both material and nonmaterial 
links between the network and ego. Thus, the strong posi- 
tive association between nonwhites and network emotional 
bondedness may carry over to result in an overall feeling of 
an even give and take between ego and his or her network. 
Secondly, as the perceived measure was obtained in response 
to a direct question to the believed sense of balance in a 
network relationship any "no" responses would be more ap- 
parently in conflict with the norm of reciprocity. This may 
be adhered to more strongly by nonwhites than by whites. 
Hence, there would be less likelihood for a negative re- 
sponse by nonwhites. 

Socioeconomic Differences 
As might have been expected, money did make a differ- 
ence. Controlling for sex, race, and health (both physical 
and mental) , both the objective and perceived measures of 
network tie directionality, the size of ego's nonrelative 
network with at least one material link to ego, and the mean 
network emotional bondedness to ego varied significantly 
with socioeconomic status. However, there was no 



124 

significant relationship between state-financed and private 
payers in terms of ego's total personal network size, net- 
work density or degree, the proportion of instrumental 
links, or the mean network visits, speaking, or writing to 
ego (see Appendix I, Table 1-3) . 

Private payers had a significantly higher proportion of 
reciprocated links in both their total primary network 
(p < .001) and in their relative subsector (p < .005). They 
also had a significantly lower proportion of dependent links 
in both their total primary network (p < .005) and relative 
subsector (p < .05) than did state-financed residents. 
Additionally, private payers perceived their relationships 
with the members of their primary network to be more bal- 
anced than did state-financed residents (p < .05) . 

This indicates that those whose ACLF care is state- 
financed have generally been more dependent on their primary 
network for assistance than the private payers at the point 
of their move into the ACLF. They have not been able to 
repay their network for services rendered to the same degree 
as those with more financial resources. Thus, it is not 
surprising that their networks looked for state help to 
relieve them of one more ego related "burden." 

This relationship did not remain when ego's nonrelative 
subsector was analyzed. There was no association with link- 
age directionality in ego's nonrelative sector and ego's 
socioeconomic status, regardless of whether directionality 



125 



was measured objectively or subjectively. However, amongst 
ego's nonrelative sector only, there was a difference in the 
size of those with at least one material link to ego by 
socioeconomic status. Those whose care was state-financed 
were materially linked to a greater number of nonrelated 
"close others" than those whose care was privately financed. 
It is not surprising that while this nonrelative sector was 
exchanging forms of assistance with ego prior to his/her 
move to the ACLF, these "close others" were not willing to 
extend this assistance to the point of paying for part or 
all of ego's ACLF care. This finding is consistent with 
that of Cantor (1979) who found very few elderly (8.5%) who 
were willing to look to either friends or neighbors for 
major forms of financial assistance. 

Not only were the state-financed more dependent upon 
their network when they entered the ACLF, they were also 
less emotionally bonded to both their total primary network 
(p < .005) and to their relative network (p < .005) . How- 
ever, once again, this relationship was not found in ego's 
nonrelative sector. 

One can only speculate as to the pattern of 
causality among these variables. It is plausible to postu- 
late that decreased network emotional bondedness is a conse- 
quence of ego's unreciprocated dependence on his or her 
network and a precipitator of these networks' increased 



126 

tendency to relinquish the financial responsibility for 
ego's care to the state. 

While ego's financial resources influenced the degree 
to which ego was able to "repay" assistance from his or her 
network, ego's financial resources were not associated with 
the degree to which ego's assistance to his or her network 
was "repaid" by the network. Private payers did not have a 
significantly greater proportion of instrumental links with 
their network than did state-financed residents. As instru- 
mental links occurred primarily when assistance rendered 
earlier by ego to one of his or her children was not cur- 
rently being "repaid," these results indicate that ego's 
financial resources were not associated with the degree to 
which ego's children were providing assistance to ego. Pos- 
sibly this may be explained by an overriding effect of ego's 
geographic proximity to his or her children. Yet, as mat- 
erial links could include money or gifts (neither of which 
are limited by distance) geographical distance is not a 
sufficient explanatory factor. More likely, the degree to 
which ego's children provide assistance to ego is associated 
with their attitude toward ego. And, if this is the key 
causal factor, this pattern of material linkages will be 
highly resistant to change. 



127 

Health-Related Differences 

Controlling for the structural variables race, socio- 
economic status, and sex, four characteristics of ego's 
personal network varied significantly with ego's health 
status: density, network bondedness to ego, the average 
frequency of network member's written and visiting contacts 
with ego, and the proportion of instrumental links. Neither 
ego's physical nor mental health was related to ego's net- 
work size, degree, proportion of reciprocated or dependent 
links, perceived proportion of balanced network relation- 
ships, or the mean verbal communication with ego by network 
members (see Appendix I, Table 1-4) . 

The density of ego's total network was inversely re- 
lated to both ego's level of competence or mental ability 
(p < .0001) and to ego's self-care ability at the time of 
his/her move into the ACLF (p < .05) . However, when the 
relative and nonrelative subsectors were analyzed separ- 
ately, this relationship was not significant. Thus, it was 
the manner in which these subsectors related; i.e., the 
percentage of possible links that were actualized in ego's 
total primary network, that was associated with ego's health 
at the time of his/her move into the ACLF. 

The reasons for this association are postulated in the 
multiple consequences of network density on the reaction of 
ego's network to ego's person-environmental fit. First, 
given that network density is indirectly related to the 



128 



degree of network openness, the greater degree of impairment 
in ego's health status at the time of his/her move into the 
ACLF may be explained by the decreased number of information 
channels to assist with the labeling and referral of ego's 
problem. This then, may result in the overlooking of ego's 
problem until it becomes relatively severe. 

As is discussed in Chapter Nine, another, possibly more 
important set of explanations, may be contained in the 
"supportive" character of dense networks. The greater per- 
centage of internetwork linkages may allow for more dis- 
persion of the burdens of caring for ego in his/her home or 
the home of a network member, as well as increase the pres- 
sure on network members to continue to assume those respon- 
sibilities. This would contribute to the postponement of 
ego's relocation until his/her condition became more severe. 

Yet, while those who were able to delay their relo- 
cation into an ACLF until they were more impaired belonged 
to more dense total personal networks, those networks were 
not more emotionally bonded to ego. The association between 
mean network emotional bondedness and ego's health was only 
present in ego's nonrelative sector, and this was only true 
when ego's physical health was analyzed. Those who were 
more limited in their self-care abilities when they came to 
the ACLF were more emotionally bonded to their nonrelative 
network (p < .05) . 



129 

In terms of the interactional variable, contact fre- 
quency, network differences were found only in relationship 
to ego's level of mental competence. There was no differ- 
ence in the frequency or method of network contact with ego 
on the basis of ego's self-care ability. Those who were 
incompetent were in less frequent written contact with both 
their total personal network and relative network (p < .05) 
and tended to have a greater number of visits (p < .10) with 
their relative network members than did those with a compe- 
tent mental health status. 

The difference in ego's contact by writing with network 
members by mental impairment is not surprising. It is to be 
expected that while one's physical health would not neces- 
sarily influence one's ability to communicate effectively by 
mail, being mentally impaired would negatively affect this 
mode of communication. However, the explanation for the 
increased visiting pattern of the relative network members 
of those more mentally impaired is not as obvious. The most 
likely explanation is that when ego is mentally impaired, 
face-to-face contact is probably the only way his/her net- 
work can meaningfully communicate with ego. Hence, this 
mode of contact comes to be preferred by the network, and is 
chosen more frequently. Conversely, one's degree of physi- 
cal impairment would not necessarily limit other modes of 
meaningful communication, thus dispersing ego's contact 
among visiting, the telephone, and writing. 



130 



The only association between linkage direction and 
ego's health was in the proportion of instrumental links in 
ego's total network, and this was only for ego's level of 
self-care ability. Ego's level of self-care impairment was 
inversely related to this directionality measure (p < .05) . 
There was no relationship with ego's health and the propor- 
tion of dependent or reciprocated links or in ego's per- 
ceived balance of the give and take with his/her network 
members. This indicates that, in general, the pattern of 
material links with ego and his/her network was not influ- 
enced by ego's health status. Rather, as was discussed 
earlier, ego's socioeconomic status was a much more impor- 
tant variable. 

While network size (both as defined in this study and 
with the further requirement of the existence of at least 
one material link with ego) was not significantly related to 
ego's health, the mean network size of those in poor physi- 
cal and mental health was generally smaller than the network 
size of those whose presenting health was higher. The lack 
of a significant relationship by size and mental health 
status runs contrary to the results reported by Pattison, 
DeFrancisco, Wood, Frazier, and Crowder (1975) and 
Solkovosky et al. (197 8). However, neither of these two 
studies controlled for any structural variables when they 
examined the relationship between ego's network size and 



131 

ego's mental health status. Thus, this picture is a bit 
more complete. Although these findings are different, they 
are not incompatible with the findings of prior research. 

In conclusion, at the time of ACLF entry both morpho- 
logical and interactional network differences were present 
between whites and nonwhites, males and females, private 
payers and state-financed residents, and those who were of 
relatively good health and those who were incompetent or had 
at least one self-care deficit. Significant differences 
were found in density and degree, network size, the number 
of people materially linked to ego, network emotional bond- 
edness, perceived and objective measures of linkage direc- 
tionality, and the patterns and frequency of ego's contact 
with network members. Interactional between-group differ- 
ences were shown for race, sex, socioeconomic status, and 
health. Structural between-group differences were demon- 
strated for race, sex, and health only. 



CHAPTER EIGHT 
THE PROCESS OF INSTITUTIONALIZATION 



Labeling and Referral 

Data on the process by which ego was labeled "out of 
place" and referred were obtained from both ego and alter, 
allowing the researcher to note any perceptual differences 
from the different sources of "the truth." Unlike the 
comparison of paired ego and alter network data, in this 
case ego's and alter' s perception of the process ACLF entry 
was significantly different. Ego was more likely to identi- 
fy a formal network member as the source of the label and 
alter was more likely to attribute this function to an 
informal network member (p < .05). A similar tendency was 
revealed for ACLF referral (p < .10) . Ego once again was 
more likely than alter to attribute this function to a 
professional. However, there was no significant difference 
between ego's and alter 's perception of the source of ego's 
ACLF payment. 

While these perceptual differences may be attributed to 
the blame dispersion tactics used by ego's informal network 
that are discussed later in this chapter, for the purpose of 
data analysis it was decided to consider alter as the 
preferred source of "the truth" as both ego and alter iden- 
tified ego's primary network as the one usually responsible 



132 



133 

for both the labeling and referral process. Thus, these 
responses were considered as primary data sources, with 
information from ego substituted when alter responses were 
missing. As only six alters were not interviewed, any 
substitution effect should be minimal. 

The distribution of the types of network members attri- 
buted with the labeling and referral of new residents is 
illustrated in Table 8-1. Information on the relative con- 
tribution of both the aggregated categories, formal and 
informal, as well as the subcategories of self, relative, 
nonrelative personal network member, physician, and other 
health professional, in the process of ACLF relocation is 
outlined. These results show the importance of the informal 
network in both the labeling and referral process. Over 
two-thirds of the respondents had their lack of fit identi- 
fied by an informal network member, and approximately the 
same percentage identified the informal network as the 
source of ACLF referral. Furthermore, it seems that the 
informal network did little to discourage ego from moving 
once the labeling and referral process had occurred, as only 
2.5% of the respondents admitted to having either friends or 
relatives trying to discourage them from moving into the 
ACLF. 

Within this informal network, relatives were identified 
as playing the primary role for both phases of entry, with 
over 50% of the total labelings and referrals attributed to 



134 



Table 8-1. Percentage distribution of the source of the 

"out of place" label and ACLF referral for new 
residents 



Serving as Source of 



Type of Network Member 



Label 



Referral 



Informal members: 
Relative 

Nonrelative close other 
Self 



56.8 
3.7 
7.4 



53.1 
8.6 
4.9 



Formal members: 
Physician 
Other health professional 



16.0 
16.0 



8.6 
24.7 



Total percentage 



99.9 



99.9 



Total percentages do not equal 100.0 due to rounding. 



135 



this source. While the function of nonrelative primary 
network members was relatively rare in terms of labeling, a 
larger percentage identified them as the source of ACLF 
referral. 

Possibly the most interesting finding in terms of the 
informal network is the fairly small percentage of respon- 
dents who identified ego as the one who determined that 
he/she no longer "fit in." Given the profound consequence 
of having to move out of one's home or current place of 
residence (which is likely to occur with the imputation of 
this label) perhaps it is not surprising that the elderly 
are reluctant to attribute this type of deviance to them- 
selves. 

Ego's role was even smaller when it came to identifying 
an ACLF as a relocation site, with only 4.9% of the respon- 
dents attributing this function to ego. Thus, unlike in the 
findings of Tobin and Lieberman (1976), ego's role in this 
process was found to be secondary to that of key others, 
with the importance of relatives predominating. 

This difference in findings may be explained, at least 
in part, by this researcher's more inclusive sample. Tobin 
and Lieberman (1976) systematically exlcuded those too phy- 
sically or mentally frail to be interviewed. It is this 
group which is most likely to be orchestrated into a 



136 

long-term care facility by professionals or personal net- 
work members. 

The relative importance of professionals, particularly 
physicians, in the labeling and referral process is secon- 
dary to that of ego's informal network. This finding is 
consistent with that reported by Tobin and Lieberman (1976) , 
Habenstein, Keifer, and Wang (1976), and by Florida's Office 
of Management and Evaluation Review (1985) . Given physi- 
cians' traditional focus on the physiological variables 
influencing one's health, it is not too surprising that they 
tend to overlook the environmental variables influencing the 
health of their clients. It seems that even when a physi- 
cian did identify ego's situation as a problem, ACLF refer- 
ral was just as likely to be made by another source as by 
the physician. In fact, only 8.6% of the respondents iden- 
tified a physician as the primary referral source. Other 
health professionals (primarily social workers) were by far 
the most important professional referral agent. 

One possible explanation for the apparent lack of phy- 
sician involvement in the process of institutionalizing the 
frail elderly may be found in the study's sample. This 
study is looking only at those elderly who have relocated 
to an ACLF, and hence does not include data on the elderly 
who have been newly relocated into nursing homes. Possibly, 
when physicians are involved in this process, they tend to 
refer ego to this later type of a facility. This would 



137 



indicate that while physicians are not very involved in 
entry into an ACLF, they are involved in the process of 
institutionalizing the frail elderly. If this is indeed the 
case, it would be interesting to determine the basis for 
this differential referral pattern. 

The Situation before the Move 
Once again, due to the importance of ego's informal 
network in the relocation process, alter was considered as 
the primary informational source with substitutes from ego 
used only when alter responses were missing. However, un- 
like the data on labeling and referral, this information was 
obtained from compiling answers to a broad, open-ended ques- 
tion and there is a greater incidence of missing data among 
alter responses (don't knows ranged from n = to n = 15 for 
the various categories coded) . This resulted in more ego 
substitutions as data sources than in the data obtained from 
fixed response questioning. As ego substitutes were not 
always available some don't know responses remained. 

This researcher lends support to the contention that 
relocation of the elderly to a nursing home or ACLF is 
generally done only after all other perceived alternatives 
have failed (Brody, 1977; Habenstein, Kiefer, and Wang, 
1976; Hilker, 1983; Lowenthal-Fiske, 1964; Shanas, 1979; 
Tobin and Lieberman, 1976) . In all but 5% of the cases, ego 
was already dependent upon somebody else for help (see Table 



138 



8-2) . This supportive role was primarily held by relatives 
with official agencies remaining on the periphery. In fact, 
while nearly half of the new residents had been living with 
relatives and an additional 31% of them had been receiving 
assistance from relatives while remaining in their own 
homes, less than 15% had been receiving any formal support 
services just prior to their move. 

The reason for the low involvement of formal agencies 
is unclear from these data. As this portion of the inter- 
view emphasized the situation just prior to ACLF entry, it 
is possible that formal agencies had assisted with ego's 
needs earlier, thus boosting these agencies actual per- 
centage of involvement. Yet, as informal network members 
were also ego's primary labeling and referral sources, it is 
likely that these results simply underscore the relatively 
high degree of noninvolvement by formal agencies in the 
process of ACLF entry for the majority of the new residents. 
As a more extensive utilization of formal services may have 
worked to prolong the stay of some of the new residents in 
the community the reasons for these findings need to be ex- 
plored further. 

Critical incidents commonly surfaced as key contribu- 
tors to the decision to relocate ego, or, alter talked at 



139 



Table 8-2. Frequency and percentage distribution of the 

new residents' living conditions prior to ACLF 
entry 



Living Conditions Prior to 

ACLF Entry Frequency Percentage 



Living in own home: 

Without any help 

With help of informal network 
only 

With help of official agencies 
only 

With help of informal network 
ajad. official agencies 

Living with family: 

With help of informal network 

only 34 42.0 

With additional help of 
official agencies 

Living in another ACLF 

Living in a nursing home 

a 
TOTAL 

a 
Total percentage does not equal 100.0 due to rounding. 



4 


4.9 


18 


22.2 


1 


1.2 


7 


8.6 



3 


3.7 


9 


11.1 


5 


6.2 


81 


99.9 



140 



length about the general unmanagability of keeping ego at 

home. For example, 

[Ego] did crazy things. ... He needed constant 
care. Once he stuck a screw driver in a socket 
thinking he was putting a key in a lock, 
(a daughter) 

When she urinated all over the $6,000 new carpet; 
that really made me angry. (a daughter) 

I was afraid for Grandma's life if I kept her 
home any longer. ... It got to the point 
where I had to put bars on the windows to keep 
her in the house. . . . And then she tried to 
squeeze through the bars. (a granddaughter) 

The hospitalization of ego was another type of critical 
incident that acted to push ego into an ACLF. As approxi- 
mately one-fifth of the new residents had been in the hospi- 
tal just prior to their move into the ACLF, the occurrence 
of this incident may be commonly perceived as the proverbial 
straw that broke the camel's back. However, interviews also 
revealed that for some hospitalization was used as an excuse 
to get new residents out of their homes and involve profes- 
sionals in moving them into another living situation. In 
this case network members had already perceived a need to 
relocate ego, but had not as yet been able to communicate 
that need to ego. The real purpose of hospitalization, 
thus, was to dissipate the blame for moving new residents 
out of their homes. 

In approximately one-fifth of this sample the tolerance 
of ego's network for ego's demands was limited by the recent 



141 



or ongoing illness of another network member. Either ego's 
spouse, an in-law, or possibly a son or daughter, had just 
died from or was currently struggling with a serious chronic 
illness. Given that 54.3% of this sample were over 80 years 
old, this is not too surprising. In these instances it 
seems that ego was unfortunate enough to be the second one 
to demand extensive care from his/her personal network, and 
while that same network had often been able to provide this 
support for its first failing member it was "too burned out" 
to provide it for ego. Additionally, alter frequently ex- 
pressed a feeling of having eased any sense of obligation 
"to do for" ego by already caring for another ailing network 
member. As one respondent explained, "After spending all of 
that time caring for his mother, I don't think people can 
expect us to do it again." 

Given that this move was generally undertaken when all 
else failed, it is somewhat surprising that 94.7% of the 
alters stated at the initial interview that they were gen- 
erally happy with ego's move into the ACLF. However, it 
should be noted that this satisfaction was usually cushioned 
with the attitude that the ACLF environment was "so much 
better for ego than it would be in a nursing home." This 
attitude of relative satisfaction with the move best 
expressed by some of the alters themselves. 

Mom doesn't need a nursing home now. She would 
be insulted, (a daughter) 



142 



There is a homeyness about ACLFs. . . . 

Nursing homes are pathetic. (a daughter-in-law) 

I don't want Dad in a nursing home — he's not 
at that level yet. (a daughter) 

They say you don't want to put them in a nursing 
home if you don't need them. (a daughter) 

This negative attitude toward nursing homes was also 
expressed by the the network of those who had been in a 
nursing home prior to their move into the ACLF. Approxi- 
mately 6% of the sample fell into this category. 
Interestingly, the predominant reason identified for moves 
from a nursing home to an ACLF was a depletion of ego's 
finances, and/or a termination of medicare coverage. Im- 
provement in ego's health was the second most common situa- 
tion. 

A complete absence of remorse at leaving the nursing 

home was exhibited. In fact, all of the residents and their 

networks considered the move as a situational improvement. 

Many were angry that nobody had "bothered" to alert them to 

the ACLF alternative until after ego's money had nearly run 

out. Nursing home dissatisfaction is well demonstrated in 

the following comments: 

The nursing home didn't care for [ego]. They 
just let her sit. They didn't do anything 
for her. There is no comparison with this 
ACLF. It is so much better. (a daughter) 

The nursing home was like a hospital ... so 
regimented. . . . They march down the halls 
to eat. . . . [Ego] seems much more contented 
at the ACLF. (a son) 



143 



The nursing home was the pits. [Ego] got 
no care. A nurse never went in the room, 
(a wife) 



Ego's Feelings about the Move 
Ego's feelings about the move into the ACLF were also 
determined by asking the respondent a broad open-ended ques- 
tion. However, in this instance as ego's feelings were of 
central importance ego was considered the primary informant 
with alter substitutes made as necessary. Due to 
the methodology used (don't knows ranged from n = 2 to 
n = 15 for the various categories coded) and the fairly 
large number of residents excluded from the analysis due to 
their deficient mental status and/or physical health 
(n = 30) , a large number of alter substitutes were used. 
Furthermore, as in the data on the situation before the 
move, in some cases alter substitutes were unavailable, 
resulting in remaining unknown categories. 

Ego shared alter' s aversion to nursing home residence. 
In all but two cases ego felt better about moving to an ACLF 
than to a nursing home. Many residents expressed an intense 
desire to avoid nursing home placement at all costs. This 
is well demonstrated in such comments as 

Convalescent homes are insane asylums, 
(a male resident) 

When they take me to a nursing home, they can 
get a gun. (a male resident) 



144 

Nursing homes are like the plague, (a female 
resident) 

Not only did the residents not want to be in nursing 
homes, they also felt that they did not belong there. While 
it may be alright for them to move to an ACLF, a nursing 
home definitely was not the appropriate place for them. 
ACLF's were recognized as places of more personal freedom 
than nursing homes, and by many respondents they were also 
seen as a place of more freedom than would be experienced in 
their childrens' homes. As one resident so aptly stated, 
"This is the best way to optimize my independence. I can do 
for myself here. ... I am more independent here than I 
would be living with my daughter." Yet, while a greater 
sense of "homeyness" seemed to be associated with ACLFs than 
with nursing homes, they were definitely recognized as being 
different than living in one's own home. The move was the 
best available alternative, but the ACLF "just isn't like 
home." As one respondent stated, "It's a new world here." 

In fact, while nearly half of the new residents stated 
that they had recognized their need to move to the ACLF, 
approximately one-third felt that this move was unnecessary. 
Thus, as relatives and professionals went about orches- 
trating ego's move, it was frequently against ego's will. 
Consistent with our social norms of saving face for our 
family, the residents frequently made excuses for their 
family's behavior, playing down any conflict they may have 



145 

been experiencing with their families. Yet, 16% of them 

openly expressed the anger they felt towards their family 

regarding the move. Some good examples of these feelings 

are illustrated in the following quotes: 

I am ashamed to be here. ... I have not told 
anybody where I am. (a female resident) 

[Ego] just doesn't want to leave her own 
home. . . . Yet, it is so expensive getting 
someone to cover her care there. It is especially 
difficult getting someone at night, and this is 
when [ego] is most confused. Neighbors stop in, 
but they don't really help. ... (a son) 

It's alright here. . . . Living with other 
people has its problems. I would prefer living 
with my friends, but they aren't able to take 
care of me. (a female resident) 

Thus, Streib's (197 8) concept of an amalgam group is 
probably just as appropriate for describing this type of 
living situation as it is for describing share-a- homes. The 
ACLF is recognized by the residents as being less personal 
than living in one's family, but as a situation with more 
freedom than what exists in the institutional structure of 
the nursing home. Therefore, given the similarities in 
these residents' reactions to ACLFs with those expressed in 
Hilker's study of share-a-home residents (1983), the delin- 
eation between these two categories is probably artificial. 



CHAPTER NINE 
NETWORK VARIABLES AS PREDICTORS OF ACLF ENTRY 



Each of the network variables — reciprocity, density, 
degree, and intensity — were analyzed to determine if their 
hypothesized effects on the process of ACLF relocation had 
occurred. To determine the differential effects of the 
focal networks, the analysis determined the effect of these 
variables as defined by both ego's total primary network and 
relative and nonrelative subsectors. Additionally, the sub- 
jective and objective reciprocity measures, as well as the 
dual connectivity measures — density and degree — were 
analyzed separately to minimize the problem of multicol- 
linearity. 

As density and degree can only be computed for networks 
with at least three members (including ego) , residents with 
zero or one network member in addition to themselves were 
excluded from the analysis. This only excluded 4 residents 
from the total network analysis, and 7 from the relative 
network analysis. However, 43 observations were excluded 
from the nonrelative network analysis. A separate analysis 
of these network deficient residents is found at the end of 
this chapter. 

The focal dependent variables at time 1 were the source 
of ego's labeling and referral and the severity of ego's 

146 



147 

health at the time of ACLF entry. As these dependent 
variables are both categorical and interval a combination of 
multiple and logistic regression analyses was used. A 
logistic regression was done to analyze the categorical 
dependent variables as it has been established that ordinary 
least squares is not an appropriate methodology for ana- 
lyzing dichotomous dependent variables (Aldrich and Nelson, 
1984; Swafford, 1980). The reasons for this approach are 
multiple: (a) the conditional distribution of Y is not 
normal, (b) the conditional distribution of Y is noncon- 
stant, (c) the error term is correlated with the model, (d) 
the results are highly sample specific, and (e) there is no 
requirement that Y falls between and 1 and values outside 
this range are meaningless. 

Logistic regression is a model transformation approach. 
The untransformed model is "S" shaped, bounded at P = 1 and 
P = 0, with P indicating the probability of observing a 
response of Y = 1. In this analysis both the probability of 
ego being labeled "out of place" by a professional and the 
probability of ego being referred to an ACLF by a profes- 
sional were indicated by Y = 1. 

Controls were added for sex, race, and socioeconomic 
status as they have been both theorized and demonstrated to 
have an effect on health related help seeking behavior 
(Freidson, 1970; Gove and Howell, 1974; Horwitz, 1977; 
Verbrugge, 1985). Each of these were dichotomously coded 



148 



with males, whites, and private residents coded and 
females, nonwhites, and state paying residents coded 1. 
Additional analyses were done to determine if any rela- 
tionships between the dependent variables — ego's health, the 
source of ego's label, and the source of ego's referral 
existed. 

Labeling 

It was hypothesized that the probability of ego's con- 
dition being labeled by a professional would be directly 
related to the density, degree, reciprocity, and intensity 
of ego's network ties. Additionally, due to the proposed 
importance of ego's relationship with his/her closest other, 
the effect of the intensity of this bond on the labeling 
process was hypothesized as a separate variable directly 
related to the probability of professional labeling. 

While the controls of sex and race had no effect on the 
labeling process, ego's socioeconomic status did explain the 
source of ego's "out of place" label. The state-financed 
resident was more likely to have been professionally labeled 
than the private payer (p < .05) . This finding was only 
significant when the effect of ego's total primary network 
on the labeling process was being analyzed. However, the 
trends remained for the subsector analysis. This means that 
when the state is paying for ego's ACLF care, a professional 
is more likely to have labeled ego as being "out of place" 



149 



than when the residents or their networks are assuming 
financial responsibility for ACLF care. 

The intensity of ego's network ties was the only net- 
work variable related to labeling by a professional. There 
was no relationship with network reciprocity, density, 
degree, or the intensity of ego's relationship with his/her 
closest other to the labeling process (see Appendix J, Table 
J-l) . As the intensity of ego's relationship with his/her 
total primary network increased, the likelihood of profes- 
sional labeling increased (p < .05) . 

This relationship did not remain significant for rela- 
tive and nonrelative intensity, although the trend did 
remain. These results may be explained by Cantor's (1979) 
theory of network compensation. It is not the effects of 
these sectors taken separately, but their combined nature 
that influences the labeling process. 

If both relative and nonrelative sectors are closely 
bonded to ego, they are more likely to share a sense of 
willingness or obligation to do for ego, and hence are more 
likely to tolerate ego's behavior and not label it out of 
place. However, if only one sector is closely bonded to 
ego, the other sector may interject the "out of place" label 
on ego's behavior rather than a professional, and may in- 
fluence the remaining portion of ego's personal network to 
assume a similar attitude. 



150 

Similar reasoning also explains finding no relationship 
between the intensity of the bond between ego and ego's 
closest other and the source of ego's "out of place" label. 
The intensity or strength of this one special tie is not 
sufficient to keep ego's closest other or another personal 
network member from perceiving ego's environmental fit as 
being problematic. 

While ego's closest other may share a strong, intensive 
relationship with ego and, hence, have a high tolerance 
level for ego's behavior, if the other personal network 
members do not share this type of bond with ego, any one of 
them could interject ego's "out of place" label. Ego's 
closest other may also then be persuaded to perceive ego's 
fit as problematic. In either case, the source of the label 
is a member of ego's personal or informal network rather 
than a professional. Thus, if network members are to delay 
in identifying ego's fit as problematic until it is so 
labeled by a professional, ego's personal network must, as a 
unit, share an intense, high emotionally bonded relationship 
with ego. 

Although reciprocity was not a significant explanatory 
variable its effect on the log odds of professional labeling 
varied with the indicator used. When measured subjectively, 
the relationship was in the predicted positive direction. 
However, when reciprocity was measured by the proportion 



151 

of reciprocated links in ego's network the relationship 
tended to be negative. 

An explanation for this difference in effects may be 
found in the more inclusiveness of the subjective measure. 
As discussed in Chapter Seven, while the objective measure 
addressed only material links, the subjective measure in- 
cluded both material and nonmaterial links between ego and 
network members. Thus, if network members were highly 
emotionally bonded to ego, this may carry over to result in 
an overall perception of an even give and take between ego 
and network members. As this latter relationship was indeed 
positive, the tendency for perceived balance to be posi- 
tively related to labeling by a professional is consistent. 

The tendency for objective reciprocity to be inversely 
related to labeling by a professional is directly opposite 
to what was predicted. An explanation is found in the rela- 
tionship between reciprocity and financial assistance. When 
reciprocity is higher, ego is also less likely to be finan- 
cially dependent upon network members. This implies that 
ego would be more likely to be able to pay for ACLF care. 
Possibly, network members are more likely to recognize that 
ego no longer fits when ego can afford to live elsewhere. 

The lack of support for the hypothesized direct rela- 
tionship between the connectivity of ego's personal network 
and labeling by a professional is, at least in part, 
explained by the relative percentages of the differential 



152 



sources of ego's "out of place" label (see Table 8-1). 
Only 7.4% of the respondents identified ego as the source of 
the label. Conversely, approximately 61% of the respondents 
identified a member of their personal network as the source 
of this label. Thus, as ego only rarely identifies 
him/herself as "out of place," the focal network for 
studying this process was not appropriate. Rather than 
consider ego the anchor, the network of ego's closest other 
is most likely to predict who suggested that ego no longer 
fit in his/her current environment. 

Returning to the proposition posited by Granovetter 
(1973, 1981) and Horwitz (1977) — that the degree of openness 
or density in a person's network is directly related to the 
number of information channels connected to him — one would 
then hypothesize that if ego's closest other belongs to an 
open or low-density network, he/she has a more diverse know- 
ledge base and, hence, is more likely to identify ego's 
condition as a problem. Alternatively, if this person 
belongs to a relatively closed network, it is less likely 
he/she will recognize ego's condition as a problem. Rather, 
it is more likely that the source of this label will then be 
a professional. 

In conclusion, the hypothesized direct relationship 
between the connectivity of ego's network, the degree to 
which there was an even give and take (either perceived or 



153 

"real") between ego and the members of this network, and the 
intensity of ego's relationship with his/her closest other 
and the likelihood of ego's lack of fit being professionally 
labeled were not confirmed. Rather, it is the degree to 
which ego is emotionally bonded to all of his/her personal 
network members and the ability or willingness of ego and/or 
this network to finance ego's ACLF care that predicts the 
likelihood of the informal or formal network recognizing 
ego's environmental fit as a problem that needs to be 
addressed. 

Referral 

The key question in this section of the analysis was, 
"Did the degree and density of ego's network vary directly 
with the likelihood of ego being referred to an ACLF by a 
professional?" Neither network reciprocity, intensity nor 
the intensity of ego's tie with his/her closest other were 
hypothesized to be predictors of referral. 

The hypothesized relationship between network con- 
nectivity and referral was not confirmed; neither the degree 
nor the density of ego's total primary network, relative 
subsector, and nonrelative subsector were significant pre- 
dictors of the change in the logit of formal referral verses 
informal referral. The controls of sex and race also did 
not explain the referral phase of the relocation process. 
Having one's care financed by the state did continue to tend 



154 

to increase the probability of professional involvement in 
the relocation process. However, this relationship only was 
significant in the analysis of ego's nonrelative sector (see 
Appendix J, Table J-2) . 

A reason for the lack of support for the hypothesized 
direct relationship between network connectivity and refer- 
ral by a professional is also found in the relative percen- 
tages of the differential sources for ego's ACLF referral 
(see Table 8-1). As ego's primary network is the principal 
ACLF referral source, with ego only rarely the source of 
this decision, the focal network for studying this process 
was not appropriate. Rather than consider ego as the net- 
work anchor, the network of ego's closest other (who is 
ego's most important primary network member) is most likely 
to predict who suggested that ego move into an ACLF. 

Consistent with Granovetter 's (1973, 1981) and 
Horwitz's (1977) proposition, one would deduce that if ego's 
closest other belongs to a low-density network and, thus, is 
connected to a larger number of information channels, the 
closest other will be more likely to be knowledgeable about 
ACLFs and, hence, to refer ego to an ACLF as a response to 
his/her lack of fit. Alternatively, if ego's closest other 
belongs to a high-density network his/her knowledge base 
will be more encapsulated. It is then less likely that the 
closest other will be informed of ACLFs as a possible alter- 
native living arrangement for ego and, hence, consider 



155 



referring ego to an ACLF as a response to his/her lack of 
fit. In this case, it is likely that a response for ego's 
lack of fit will be sought from a health professional. 
Utilization of the ACLF, then, becomes contingent upon the 
transmittal of this information by the professional to ego's 
closest other. 

While the relationship between degree and referral is 
not significant, the logit of degree is consistently nega- 
tive in its effect on both labeling and referral. This is 
directly contrary to what was predicted and indicates that 
as the average number of relationships members have with one 
another decreases, the log odds of both professional 
labeling and professional referral increases. 

This suggests that this connectivity indicator affects 
network information rendering somewhat differently than 
density. An explanation may be found in the confounding 
variable — size. While density is the percentage of poten- 
tial connections that do in fact exist, degree measures the 
average number of connections that exist between network 
members. Thus, while density is proposed to affect the 
external availability of information to network members, it 
seems that degree affects the availability of information to 
network members from within the network. As the average 
number of relationships members have with each other 
decreases, the potential sources of information among 



156 

network members decreases. As this researcher has deter- 
mined that the knowledge of ego's closest other is most 
critical in the labeling and referral process, it is then 
hypothesized that as the degree of ego's closest other's 
network increases and, hence, the potential within-network 
sources of information increases, the likelihood of profes- 
sional labeling and referral decreases. Testing of this 
hypothesis remains for future research efforts. 

Returning to the control variables, as socioeconomic 
status explained the source of both the "out of place" label 
and ACLF referral, the analysis was taken a step farther to 
determine if the source of labeling would predict the source 
of referral. Controlling for ego's socioeconomic status, 
sex, and race a highly significant finding emerged between 
the source of ego's "out of place" label and the source of 
ego's referral (p < .001). The network that initiates the 
process of moving ego into an assisted living situation will 
most likely decide the location of ego's move. If ego is 
labeled by a professional it is very likely that he/she will 
be referred to the ACLF by a professional. Similarly, if 
ego is labeled "out of place" by a member of his/her primary 
network, it is very likely that ego will be referred to an 
ACLF by a primary network member. 



157 

Ego's Presenting H ealth Status 
It was hypothesized that the severity of ego's health 
at the time of the move into the ACLF would be directly 
related to the density, degree, reciprocity, and intensity 
of ego's network ties. Additionally, the intensity of the 
relationship with ego's closest other was also predicted to 
be directly related to the severity of ego's mental and 
physical health at the time of the move. 

While the effect of the independent variables differed 
by focal network and the health indicator (with the model 
generally explaining a higher proportion of the variance in 
ego's presenting mental than physical health) density, 
degree and closest other intensity were all found to be 
significantly related to ego's health at the time of the 
move (see Appendix J, Tables J-3 and J-4) . The controls — 
sex, race, and socioeconomic status — had no effect. 
Additionally, controlling for ego's sex, race, and socio- 
economic status, there was no relationship between the 
severity of ego's presenting health status and the source of 
ego's label or referral. 

The density of ego's total network was directly related 
to both the severity of ego's mental health (p < .001) and 
to ego's level of dependence in the activities of daily 
living (p < .05) at the time of the move. However, when the 
relative and nonrelative sectors were considered, the 
density of these sectors was not related to ego's mental 



158 



health. Only the density of the relative sector explained 
ego's presenting self-care ability (p < .05). These findings 
also suggest that it is the structure of ego's total primary 
network rather than the structure of either of the 
subsectors of this primary network that has a critical 
effect on the process of ACLF entry. 

Furthermore , when the effects of the other character- 
istics of ego's total network are compared to the effect of 
density on ego's presenting health status, results indicate 
that all of the interactional characteristics have a much 
lower explanatory power (see Table 9-1) . Thus, the impor- 
tance of total network density on delaying ego's ACLF entry 
is further underscored, suggesting, as do the findings of 
Sokolovsky et al. (1978:14) that "persons with small, poorly 
connected networks represent an at-risk group requiring 
added professional support if they are to remain out of an 
[institution] . " 

Reasons for these findings are multiple. As the 
analysis of the effect of connectivity on the labeling and 
referral process failed to take into account the 
connectivity of the network of ego's closest other, it can 
only be speculated that the effect of density on ego's 
presenting health status is due in part to differences in 
information for problem recognition and help seeking. 
Support for this hypothesis must wait for future study. 



159 



Table 9-1. Variable effects on ego's presenting health 

severity, standardized regression coefficients 
(N = 77) 





Effect 
Mental 


on Ego's 
Health 


Effect or 
Physical 


i Ego's 
Health 


Variable Name 


B 




SD 


B 


SD 


Total density 


.38*** 




.01 


.29** 


.01 


Total network 
bondedness 


-.07 




.04 


.13 


.08 


Closest other 
bondedness 


.19* 




.05 


.07 


.09 


Total network 












reciprocity — 
"objective" 


.17* 




.48 


-.05 


.79 


SES 


-.08 




.37 


-.04 


.66 


Sex 


.04 




.26 


.11 


.47 


Race 

2 
R 


-.13 
.21 




.38 


-.09 
.09 


.68 



*p < .10. 
**p < .05. 
***p < .001. 



160 

Hammer's (1963) posited explanation of the increased 
supportive nature of dense verses loose-knit networks is 
also a plausible rationale for these findings. A dense 
network structure facilitates intranetwork support for 

The substitution of degree for density in the regres- 
sion equations generally resulted in a substantial lowering 
in R-square, indicating that density is also more useful 
than degree in explaining ego's presenting health status. 
Furthermore, while the proportion of ego's network members 
who were in regular contact with each other was directly 
related to the severity of ego's presenting health status, 
once again, there was a tendency for the degree of ego's 
total primary network and relative subsector to decrease as 
ego's presenting health status worsened (see Appendix J, 
Tables J-3 and J-4) . 

As with the relationship with degree and labeling and 
referral, this result is directly opposite to what was pre- 
dicted. Once again, an explanation may be found in the con- 
founding variable, network size. While those with decreased 
presenting health status belong to networks where a higher 
percentage of members are in regular contact with each 
other, this does not imply that these networks are in fact 
larger. Conversely, while there is not a significant dif- 
ference in network size by ego's health status, size does 
tend to decrease with the increased severity of ego's pre- 
senting health (see Chapter Seven) . The decreased size of 



161 



these networks would then limit network degree. Thus, while 
network density varies directly with the severity of ego's 
health status, an inverse relationship tends to exist 
between ego's presenting health severity level and degree. 

One exception to this unanticipated trend was found. 
The degree of ego's nonrelative network was directly related 
to ego's level of dependence in activities of daily living 
(p < .05) . This result is congruent with the hypothesized 
relationship between ego's health and degree. The higher 
the degree of ego's nonrelative network, the lower ego's 
presenting self-care level. Thus, in spite of the fact that 
frail residents tended to have less members in their non- 
relative sectors, these nonrelative networks members had a 
higher average number of intranetwork relationships than 
those who were less physically frail at the time of their 
move. 

The positive relationship between reciprocity and ego's 
presenting health severity level was not confirmed. There 
was a trend in this direction, but this was only with ego's 
presenting mental health status and the proportion of reci- 
procated links in ego's total primary network (p < .10). 
Subjective reciprocity tended to decrease as ego's 
presenting mental health status worsened, and in terms of 
ego's physical health no consistent relationship emerged 
with either linkage directionality measure. 



162 

This weak support for the relationship between recipro- 
city and ego's health may be explained by the effect of 
ego's declining health on his/her ability to continue to 
reciprocate network members' services. If indeed, ego's 
network acts to maintain ego at home for a longer period 
when there are more reciprocal ties between them, as ego's 
condition worsens, it is to be expected that ego's ability 
to reciprocate for network services will decrease. Thus, 
while there may at one time have been a difference in the 
proportion of reciprocated ties between those who stayed at 
home longer versus those who did not, these differences 
should not be significant at the time of the move. 

As was predicted, the intensity of ego's relationship 
with his/her closest other tended to be directly related to 
the severity of ego's presenting physical and mental health 
status. However, a significant relationship was only demon- 
strated when analyzing the effect of nonrelative network 
variables on ego's presenting mental health status 
(p < .05). 

This means that when ego had a nonrelative network of 
greater than two members (including ego), the intensity of 
ego's relationship with his/her closest other had the 
greatest effect on delaying ego's ACLF entry until ego's 
mental health status was quite poor. Thus, it seems that 
the additional factor of the existence of two or more non- 
relative close others in one's primary network increases the 



163 



effect of closest other intensity on delaying the move to 
the ACLF. 

The importance of ego's nonrelative network is further 
emphasized by comparing the impact of network variables by 
focal network (see Appendix J , Tables J-3 and J-4) . While, 
as was explained earlier, the density and the degree of 
reciprocity in ego's total network have a greater effect on 
ego's presenting health severity than do these subsector 
characteristics, when the effects of network characteristics 
are considered as a unit the greatest proportion of variance 
in both ego's presenting mental and physical health is ex- 
plained by nonrelative network variables. 

The predicted positive relationship between network 
bondedness and ego's presenting health severity was not 
significant. In fact, as ego's presenting physical health 
worsened nonrelative bondedness tended to decrease 
(p < .10). The lower ego's presenting physical health 
status the less emotionally bonded ego tended to be to 
nonrelative network members. If a highly bonded network 
does keep ego home longer, thus allowing ego's presenting 
health status to worsen, over time this emotional bondedness 
may decrease due to the strains of maintaining ego at home. 
Nonrelative close others may be less resilient to the de- 
mands of caring for an ailing network member than are rela- 
tives. This would result in no bondedness difference by 



164 

ego's presenting health level, or the observed reversal in 
bondedness. 

The strain of caring for ego and the resultant declines 
in network bondedness may also account for the reported 
negative trend in perceived reciprocity and ego's presenting 
mental health. As discussed earlier in this chapter, the 
subjective measure of reciprocity contains both material and 
nonmaterial linkage dimensions. Declining network bonded- 
ness may carry over to result in an overall perception of an 
uneven give and take between ego and network members. 

In conclusion, while high network density and having a 
high intensity relationship with a close other did have the 
effect of maintaining ego at home until his/her health 
became more severe, keeping ego home had a stressful effect 
on networks. This was evidenced in decreased network bond- 
edness with ego and lower network degree. Furthermore, 
while the density of ego's total network was shown to have 
the greatest total network effect on ego's presenting health 
status, as a unit the characteristics of ego's nonrelative 
network explain ego's presenting health status to a greater 
degree than do relative or total network variables. 

Network Deficient Residents 
As noted earlier, the concept of network deficiency is 
understood here in terms of size only, with deficiency being 
defined as an "n" of less than three (including ego). The 



165 

reason for this definition is primarily due to the fact that 
density and degree figures are meaningless for networks of 
this size, and hence the data on these individuals is lost 
from all analyses that examine or control for density and 
degree. It is also recognized that frail elderly people 
with very small or nonexistent personal networks are more at 
risk of institutionalization. Thus, it is important that 
data on this subgroup be examined. 

It was unusual for the new residents to have no more 
than one person that they felt close to and had been in 
regular contact with prior to entering the ACLF. Only 4.9% 
(n = 4) of the sample had this sparse a total primary 
network. Similarly, all but seven (8.6%) of the respondents 
were in regular contact with at least two relatives whom 
they felt close to. However, 45.7% of the sample had a 
deficient nonrelative network. Thus, it was not unusual for 
these people to come to the ACLF with only one or no 
nonrelatives whom they felt close to. 

Deficient Total and Relative Networks 

Due to the small number of respondents with a deficient 
total primary network and/or a deficient relative sector, 
Fisher's exact test was used to determine if significant 
differences existed between these groups and those who had 
at least two members in each of these networks. As the size 



166 

of the deficient group made the power of the test relatively 
low, any significant findings are particularly noteworthy. 

While those with a deficient total and/or relative 
network were not any different from those with nondeficient 
networks by race or marital status (they, too, are 
predominantly white and unmarried) , a tendency existed for 
those deficient in their total primary network to be male 
(p < .08) and of lower socioeconomic status (p < .18) . 

Additionally, this network deficient group did not 
enter the ACLF with a significantly different physical or 
mental health status, and there was no difference in their 
level of perceived health. As discussed by Lowenthal-Fiske 
(1964) , this may be explained by two opposing preentry 
conditions, which in tandem would tend to result in no 
significant difference: (1) if ego is with few or no signi- 
ficant others his/her "out of place" condition may go un- 
noticed until ego's health is extremely bad, and (2) if 
early contact is made with formal agencies, they will have 
less complimentary informal network services to work with, 
thus making ego's environment less accommodating, and re- 
sulting in ACLF entry when ego's health is relatively 
better. 

In terms of the process by which the network deficient 
residents came to move into the ACLF some important 
differences emerged (see Tables 9-2 and 9-3) . Both those 
deficient in their total network (p < .01) and those 



167 



deficient in their relative networks (p < .05) were more 
likely to be formally than informally labeled as "out of 
place" in their current environment, and the professional 
mentioned was always one other than a physician. In fact, 
all of those with deficient total networks were formally 
labeled. 

The more prevalent role of professionals in 
orchestrating the move of those with deficient total and 
relative networks was also demonstrated in the differential 
source of ACLF referral. Once again, the professional 
mentioned was always one other than a physician. However, 
in this case only the total network deficient group was more 
likely to be professionally referred (p < .05) . 

As with the nondeficient group, once the decision was 
made, delays and discouragement were unusual. In fact, none 
of these people identified any discouragement from others in 
regard to their move, and only one of them experienced any 
delay after their decision was made. 
Deficient Nonrelative Network 

The demographic profile of those with a nonrelative 
deficient subgroup was not significantly different than that 
of those with two or more nonrelatives to whom they felt 
close to and with whom they were in fairly regular contact. 
A chi-square analysis revealed no difference in the sex, 
socioeconomic status, race, or marital status between them. 



168 



Table 9-2 Frequency comparisons of labeling sources by 
deficient and nondeficient network groups 





Network Group 


Deficient 
Relative 




Labeling 
Source 


Deficient Nondeficient 
Total Total 


Nondeficient 
Relative 


Formal 


4 22 


5 


21 


Informal 


55 


2 


53 


Total 


4 77 


7 


74 


Fisher's 
Exact 
Test 


8.79** 


5 


.37* 



*p < .05. 
**p < .01. 



169 



Table 9-3. 



Frequency comparisons of referral sources by 
deficient and nondeficient network groups 



Network Group 



Referral 


Deficient 


Nondeficient 


Source 


Total 






Total 


Formal 


4 






23 


Informal 









54 


Total 


4 






77 


Fisher's 










Exact 










Test 




8. 


,31* 





Deficient Nondeficient 
Relative Relative 



4 
3 

7 



23 
51 
74 



1.93 



>p < .05. 



170 



Similarly, a Kendall's tau analysis indicated that there was 
no educational difference between those with two or more 
nonrelative "close others" and those with only one or no 
close nonrelative relationships, and an analysis of variance 
revealed no age differences between these two groups. 

In terms of the process by which the residents came to 
enter the ACLF, belonging to a deficient nonrelative network 
did not make a significant difference in the source of their 
label or referral, the degree to which their proposed move 
was discouraged by network members, or to the degree to 
which their entry was delayed after the decision to move was 
made. However, while an analysis of variance indicated 
that those with deficient nonrelative networks did not 
enter the ACLF at significantly different levels of physical 
health than did those with more than one nonrelative "close 
other," nor did they perceive their level of health 
any differently, those deficient in their nonrelative 
network had a decreased mental health status at the time of 
ACLF entry (p < .005) . Thus, if a large supportive group of 
nonrelative close others had acted to assist the rest of 
ego's primary network in delaying his/her ACLF move, by the 
time this move actually was accomplished this group had 
dwindled to zero or had only one member. 

In terms of the rest of their primary network, those 
lacking in nonrelative significant others had not 



171 

compensated by maintaining a larger relative network. There 
was no significant difference in the size of the relative 
networks between these groups. This finding runs somewhat 
counter to Cantor (1979) who found a more active friendship 
network among those without nearby children. 

In conclusion, network variables were found to be re- 
lated to the ACLF relocation process in four ways. First, 
the degree to which ego is emotionally bonded to his/her 
total personal network was directly related to the prob- 
ability of ego being professionally labeled as "out of 
place." Second, while the connectivity of ego's network did 
not influence the source of ego's "out of place" label or 
ACLF referral an explanation for this may be sought in the 
characteristics of ego's closest other's network, as a mem- 
ber of ego's informal network was primarily responsible for 
orchestrating ego's move. Third, having a primary network 
with less than two members other than ego increased the 
likelihood of ego's condition being both formally labeled 
and formally referred; and having less than two close rela- 
tives increased the likelihood of ego's condition being for- 
mally referred only. And, fourth, ego's presenting health 
status is directly related to the density of ego's primary 
network, the intensity of ego's relationship with his/her 
closest other, and the degree of ego's nonrelative network. 

In terms of the control variables, while neither sex, 
race, nor socioeconomic status had any effect on ego's 



172 



presenting physical or mental health status, socioeconomic 
status was found to explain both the source of ego's "out of 
place" label and the source of ACLF referral. Having ego's 
care financed by the state increased the likelihood of both 
formal labeling and formal referral. Finally it was demon- 
strated that the network source of ego's labeling and ACLF 
referral is likely to be consistent. These relationships 
are illustrated in Figure 9-1. 



173 



Intensity of 

relationship with 
significant other 



Network emotional 
bondedness 



Density 



Degree 



SES (state-rate) 



Severity of health 
•*> at time of move 




Labeling by a 
5> professional 



Referral by a 
professional 



Figure 9-1. Variable effects on the process of ACLF entry 

Note: Race, sex, and reciprocity are omitted as they 
were not significant at p < .05. 



CHAPTER TEN 
THE PARTICIPANTS: 
THE RESIDENTS SIX MONTHS LATER 



As noted in Chapter Five, an alternative strategy was 
used for data collection at Time 2. As the resident was the 
one "closest to" the information sought at follow-up, ego 
was considered the primary informant. Thus, while a follow- 
up contact with ego was attempted for all of the original 
respondents, alter was only recontacted if ego's mental or 
physical status prevented valid survey completion (n = 26) , 
if ego had moved to an out of town location (n = 3) , or if 
the family preferred that the researcher contact them 
instead of ego (n = 2). In these instances, alter' s 
responses were then substituted for ego's. 

This strategy resulted in the high follow-up completion 
rate of 88%. Six (7.4%) of the residents had died within 
this six-month period, reducing the sample size to 75. Data 
on only four (5%) of the surviving respondents were in a 
large part unavailable at Time 2 due to respondent refusal, 
or information gaps on the part of alter. 

Place of ResiriPnr.P 
The researcher found that the ACLF population is highly 
transient. Slightly less than two-thirds of the residents 
interviewed at Time 1 were at the same place of residence 

174 



175 

six months later. This means that over one-third of this 
sample had either relocated (n = 22) or died (n - 6) within 
six months of their move into the ACLF. Interestingly, more 
residents had moved home (n = 12) during this initial six 
months than had moved to another ACLF or to a nursing home 
(n = 10) . Of those, 16% returning home, four had returned 
to their own home and eight had returned to the home of a 
relative. While this pattern is consistent with that 
reported in Liu and Manton's review (1983) of nursing home 
length-of-stay patterns and Hilker's share-a-home study 
(1983) , it is quite different from that reported in Allison- 
Cooke's study (1982) of nursing home deinstitutionalization 
patterns (see Chapter Four) . 

Thus, the "problem of return" as discussed by Hawkins 
and Tiedeman (1975) was not inherent in ACLF entry. Yet, it 
could be that only those whose "out of place" label was 
conditionally legitimate (i.e., that their illness was 
assumed to be acute) were likely to return home. In fact, 
all of those who moved back to their own homes had told the 
researcher at Time 1 that they were only intending to be at 
the ACLF for a short time, and then were to return home. 
These people were using the ACLF as a short-term caring 
institution. Three were recovering from illnesses that no 
longer required hospitalization, but they were still not 
well enough to function independently at home. One had been 



176 

evicted from her home and was waiting for an opening in an 
elderly housing project. 

The "conditionally legitimate" label also frequently 
surfaced in the interviews with those who returned to the 
home of a relative. In this case ego's temporary "out of 
place" label was often due to the ill health of the relative 
who had been caring for ego. Ego's ACLF entry acted as a 
respite for the ailing relative facilitating his/her recov- 
ery which readjusted the home environment allowing ego to 
again fit in adequately. This is aptly expressed by the 
respondents themselves. 

When my sister's health improved she wanted 
me back. Neither of us [ego and her sister] 
felt good about the place. We don't like to 
be dependent. This is the way we want it. 
(a former resident) 

[Ego's] doing beautifully now, and so is his 
sister. When her health improved she wanted [ego] 
to go back. They kind of worked out their problems. 
He's more appreciative of his sister now. (a niece) 

All of those who moved to a nursing home did so due to 

a decline in their health status. Although this move was 

made reluctantly, it often resulted in giving alter more 

freedom. In contrast to the ACLF, the nursing home has 

medical care readily available, thus relieving alter from 

having to take ego to doctor appointments, or to make any 

necessary decisions about the medical management of ego's 

care. This is well explained by the daughter of one former 

ACLF resident. 



177 



While Dad was at the ACLF, I spent time with his 
affairs. I think he will be more independent of me 
now that he is in the nursing home. (a daughter) 

Perceived Fit 

Most of the respondents expressed a high level of 
satisfaction with both the physical care and the emotional 
atmosphere at the ACLF. In terms of ego's physical care, 
54% of the respondents felt that the physical care ego had 
received at the ACLF he/she had moved into six months 
earlier was excellent, and an additional 33% felt that ego's 
care had been at least adequate. Yet, nine (12%) of the 
respondents felt that this care had been less than adequate. 
Dissatisfaction with ego's care most frequently was attri- 
buted to high staff turnover, inadequate staff training, and 
inadequate dietary provisions. 

An even greater 7 8% of the respondents felt that the 
caregivers at that ACLF were not only pleasant, but, addi- 
tionally, they felt that they really cared about them. Thus, 
it seems that the "homelike" perception ego and alter held 
of the ACLF at the time of ego's move was generally con- 
firmed. The generally high satisfaction level of the resi- 
dents and their network is expressed in the following com- 
ments: 

I was scared to stay alone. I don't like to 
have an apartment again. I feel better here. I 
have no more pain. I can sleep better at 
night, (a female resident) 



178 



I couldn't handle it in my own home anymore. 
I'm too weak now f and I'm blind. They all loves 
me here. (a female resident) 

It's like living in a one-room house. As you 
get older you don't care for the responsibilities 
of a big house. It's a lot easier here. We 
have a place to eat. (a resident couple) 

It's like a family here. Now I have five 
ladies around me to talk with and help. Living 
in a group is better than living by yourself. I 
could never afford to live at home anymore. 
By the time you pay utilities and get someone 
to care for you, it is just too expensive, 
(a male resident) 

These findings suggest that ACLFs were perceived more 
favorably than Tobin and Lieberman's (1976) homes for the 
aged. Possibly, ACLFs exemplify the kind of elderly-focused 
living arrangement they are calling for in their implica- 
tions for practice. Yet, while these positive feelings pre- 
dominated, in addition to the problems identified with 
managing ego's physical care, problems related to what 
Goffman (1961) has described as the institutionalization of 
the place were also perceived by the residents and their 
networks. Residents were dissatisfied when they perceived 
their ACLF lifestyle as being either too structured or 
lacking in adequate personal freedom. Along these lines the 
following comments were expressed: 

It's a little difficult life. . . . It's more 
structured than I'm used to. (a female resident) 

I'm doing as well as can be expected. I've 
adjusted. I can't eat as often as I did. I used 
to eat small amounts frequently. . . . You're 
not your own boss anymore. (a female resident) 



179 

You call this a life? There is no lifestyle 
here. It's deadly here. We came here because 
our daughter wanted us to, but we miss our 
friends in Sun City. (a resident couple) 

Insufficient activity, and the inaccessibility of both a 

telephone and public transportation were also perceived as 

negative consequences of an ACLF lifestyle. Thus, as in 

Arling, Harkins, and Capitman (1986), and Ryden (1984, 1985) 

for some of the new residents ACLF entry was found to be 

associated with a loss of personal freedom and control, 

which then contributed to an over-all decrease in morale. 

Ego's Health 

Data on the resident's self-care ability, mental compe- 
tence, and perceived health were also attained at Time 2. 
As at Time 1, ego's self-care ability was determined by 
interviewing ego's current caregiver; his/her mental compe- 
tence level was determined by administering Pfeiffer's 
Short Portable Mental Status Questionnaire; and ego's per- 
ceived level of health was attained by asking residents to 
describe their overall health at this time. For this latter 
measure alter substitutes were used when necessary due to 
ego's unavailability or mental incompetence. 

Six months after the ACLF move, there remained a wide 
variance in the respondents' level of independence in their 
activities of daily living. While 44.6% were independent in 
all of their activities of daily living, 34% were dependent 
in at least two functions, and 3.7% were dependent in all 



180 



six assessed areas. Yet, recognizing that six respondents 
were lost at Time 2 due to their death, and one was lost due 
to significant other refusal, a paired t-test determined no 
significant changes in the self-care ability of the new 
residents during this six month period. 

This variance was also evidenced in the respondents 1 
level of mental competence. Approximately two-thirds of 
them were mentally competent and one- third were mentally 
incompetent. Once again, no significant differences in the 
new residents' level of mental competence occurred during 
this six month period. 

In terms of ego's perceived level of health, the 
majority of the respondents felt that ego's health was 
either very good (23.6%) or good (38.9%), with 27.8% of them 
describing ego's level of health as fair, and only 9.7% of 
them labeling it poor. However, unlike with the objective 
health measures, paired t-tests revealed a significant 
decrease in ego's perceived health status during this six 
month period (p < .01) . And, while a regression analysis 
revealed that perceived health at Time 2 was related to 
ego's-self care ability (p < .01) unlike at Time 1, no 
relationship between ego's level of mental competence and 
perceived health status was revealed at Time 2. 

In tandem, these results suggest that the act of ACLF 
entry does serve to redefine negatively ego's perceived 



181 

health status independently of ego's level of physical or 
mental health. Hence, support is lent to the work of 
labeling theorists which proposes that the act of entering 
an institutionalized health care setting is a critical inci- 
dent serving to impute the role of illness on one's identity 
(Scheff , 1966) . Tobin and Lieberman (1976) also demon- 
strated a change in the elderly 's health after entering a 
long-term care facility. However, in their study nonsur- 
vivorship was more noteworthy, as one out of two of those 
entering a home for the aged had either died or severely 
deteriorated after the first year. 

Alter 's Response 

Only a select subsample of 32 alters were contacted at 
Time 2. These were the significant others who were tied to 
(a) the most frail residents, those who were mentally incom- 
petent and/or dependent in multiple activities of daily 
living (n = 27) and (b) the residents who had moved from the 
ACLF and were not contactable at Time 2 (n = 5) . The 
majority (59%) of these significant others felt that their 
lifestyles had improved either slightly or greatly since ego 
had moved into the ACLF. However, a surprisingly large 37% 
of alters said that there had been no change in their life- 
styles since ego had moved into the ACLF. 

The reasons expressed for alter 's lifestyle improvement 
were a blend of feeling increased personal freedom along 



182 

with a sense of comfort and satisfaction knowing that ego 

was being well taken care of. Both of these conditions were 

said to be facilitated by the fact that ego's ACLF residence 

was convenient to alter' s work or home, which eased regular 

visits with ego. Evidence for their perceived lifestyle 

improvement is found in the following statements: 

This gives me much more freedom. I feel safe 
because she's under care. It gives me 
satisfaction that she is being taken care 
of. (a husband of a resident) 

The ACLF is scheduled around them — I wasn't. 
It's worked out really well. (a daughter-in-law) 

She's almost like she was at our house. She's 
so close I can stop by and see her almost every 
night after work. (a son) 

The mental relief is fantastic. But ego's 
money is running out. What then? (a daughter- 
in-law) 

Up until the move there was something going on 
all the time. It's an answer to our prayers, 
(a daughter-in-law) . 

While an improvement in alter 's lifestyle had been 
anticipated by the researcher, the large number of signifi- 
cant others identifying no lifestyle change was not antici- 
pated. When alter was asked to elaborate on this response, 
the predominant theme was one of continued responsibility on 
the part of alter for ego. Unlike nursing homes, the ACLF 
was not a "one-stop" medical facility for ego. Thus, alter 
was still responsible for orchestrating ego's medical needs. 
This situation is demonstrated in the following responses: 



183 



We still feel responsible, but we're physically 
unable to keep her here now. (a daughter-in-law) 

I'm still very busy doing for mother, 
(a daughter) 

I still have to take her to the doctor's, 
(a daughter-in-law) 



Interactional Network Characteristics 
Contact Frequency 

Mean network frequency of contact scores were computed 
for visiting, speaking, and writing contacts with ego at 
Time 2. Additionally, visiting and speaking frequency pat- 
terns between ego and his/her closest other were also deter- 
mined due to the importance of this special relationship to 
ego. As discussed in Chapter Five, the range was between no 
contact in the past six months (coded 1) to daily contact in 
the past six months (coded 8) . In this scale, unlike in the 
scale at Time 1, a response of not in the past year (coded 
0) was systematically excluded. All other things being 
equal, one would then expect that the mean contact at Time 2 
would be slightly higher than the mean contact at Time 1. 

However, paired difference t-tests revealed highly 
significant decreases in both the mean total personal net- 
work visiting and speaking contact scores with ego since the 
ACLF move. Parallel declines were revealed when ego's rela- 
tive and nonrelative mean contacts with ego were analyzed 
for all but relative visiting. There was no significant 
change in ego's average visiting contact with relatives 



184 



after the move into the ACLF. This is illustrated in Table 
10-1. Similarly, while speaking contact with ego's closest 
other, who was a relative for 7 8% of the respondents, did 
decline after ACLF entry (p < .05) there was no significant 
decrease in visiting frequency between ego and ego's closest 
other. 

The demonstrated continuity in visiting patterns with 
ego's relatives may be partially explained by the proximity 
of the ACLF to the home or office of the relatives who had 
been in most frequent contact with ego prior to the move. 
As discussed earlier, alter frequently reported that when 
the decision was being made for ego to enter into an ACLF 
the proximity of the ACLF to the home or work place of ego's 
relatives was an important discriminating variable. 

While this strategy was successful in facilitating 
visiting continuity between ego and his/her relatives, it 
did not facilitate continuity in visiting between ego and 
those nonrelatives whom he/she had been close to. ACLFs 
were frequently distant from the homes of these network 
members. As most of these nonrelative others were also 
older, it is likely that transportation barriers might have 
limited nonrelative tie continuity. It was unusual for an 
ACLF to be on a bus line, and driving for many of these 
older network members may have been problematic. Many of 
these nonrelative primary group members directed their 



185 



Table 10-1. Mean after ACLF entry contact differences by 
type of contract and network 







Network 




Contact 


Total 


Relative 


Nonrelative 


Visiting 


-.75** 
(70) 


-.16 
(68) 


-.84** 
(53) 


Speaking 


-1.21** 
(71) 


-.81** 
(67) 


-1.99** 

(52) 


Writing 


.71* 

(71) 


.65* 
(67) 


.90* 
(52) 



*p < .0001. 
**p < .00005. 
Uo_te: N is given in parentheses. 



Table 10-2 Before and after mean writing contact by type 
of network 



Total Relative Nonrelative 



Before After Before After Before After 
(N = 78) (N = 69) (N = 78) (N = 67) (N = 63) (N = 52) 

1.06 1.66 1.30 1.83 .65 1.58 



186 

supportive efforts toward the relatives of ego, who were 
then expected to maintain the direct material and non- 
material links with ego. This is demonstrated in the fol- 
lowing comment by the wife of a network member: 

She doesn't see . . . real often, but she helps me. 
... We go out to dinner every Sunday after church. 

ACLF entry had a greater effect on continued network 
speaking contact than visiting, as demonstrated by the over 
50% greater drop in mean speaking over mean visiting. 
Additionally, unlike Time 2 visiting, the demonstrated de- 
cline in ego's speaking contact with network members was 
also shown to occur with ego's relatives. As the speaking 
category included both visiting and telephone conversations, 
a rationale for a these differences must be found in ego's 
telephone communications with relatives. 

Telephone contact appeared to be limited to a great 
deal due to the structure of the ACLF, exemplifying what 
Goffman (1961) has identified as the low permeability of 
institutions. It was rare for a resident to have his/her 
own phone or to share a phone with a roommate. Rather, 
resident telephone access was typically limited to a cen- 
trally located community phone at the ACLF which acted to 
limit utilization due to (1) limited mobility of the resi- 
dent, (2) hesitancy of the resident to tie up the phone and 
limit business related calls or calls to other residents, 



187 

and (3) a perceived lack of privacy. This is illustrated in 

the following statements: 

They got to come and get me and take me to the 
phone. . . . It's too much work for them. (a 
resident) 

The phone is inconvenient. ... I've had to 
wean myself away from that. (a resident) 

It's not so easy to call now. . . . You call 
and call and can't get through. . . . After 
awhile, they stop calling. (a daughter) 

In addition to the structural barriers of the ACLF f 

ego's health status also frequently limited telephone 

communications. As network members of hearing impaired or 

cognitively impaired residents explained, 

It is not possible to make sense talking with 
Mother over the phone. (a son) 

It is frustrating to talk to her over the 
phone. . . . She's so hard of hearing. You 
need visual aids. (a daughter-in-law) 

In terms of written contact, results indicate a statis- 
tically significant increase in the mean frequency of com- 
munication between ego and his/her total personal network 
after the ACLF move. Parallel increases were also demon- 
strated when ego's written contact with his/her relative and 
nonrelative networks were analyzed. At first glance it is 
tempting to conclude that when ego moved into the ACLF the 
decline in speaking and visiting contact with ego and 
his/her network was compensated by an increase in written 
contact. However, examination of the meaning of these dif- 
ferent means (see Table 10-2) indicates that while there is 



188 



a statistical increase between the mean written communica- 
tion from time one to Time 2, there is no meaningful 
difference in written contact between ego and network mem- 
bers during this period. The statistical difference can be 
accounted for by the difference in scales used at Time 1 and 
Time 2. Actually, both before and after the move into the 
ACLF, ego appears to be in written contact with network 
members about once or twice a year. This was usually 
identified as being in the form of a card for Christmas 
and/or ego's birthday. 

Tie Con tent and Directedness 

Mean network material links with ego were also computed 
at Time 2. Not surprisingly, there was a significant 
decrease in the average number of material links connecting 
ego and primary network members since ego had moved into the 
ACLF (see Table 10-3) . The decrease in material links was 
demonstrated for instrumental, dependent, and reciprocated 
links in all three of ego's focal networks. 

Yet, while there was a significant decrease in ego's 
material links with primary network members, network members 
continue to exchange services, gifts, and financial assis- 
tance with ego after the ACLF move. Six months after ego 
had moved into the ACLF, he/she was on average connected 
with 7.3 material links to primary network members. As was 
the case before ego moved into the ACLF, these material 



189 



links were primarily with relatives. Relatives were con- 
nected with ego by on average 6.0 material links. Yet, non- 
relative close others were still involved with an average of 
1.2 material exchanges with ego. 

Unlike before the move when ego's greatest number of 
links were reciprocated, after moving into the ACLF ego was 
predominantly dependently linked to his/her primary network 
members. Reciprocated links were next most frequent and 
instrumental links became practically nonexistent (see Table 
10-4). In fact, in the entire sample, only five instru- 
mental links were identified at Time 2, and these were all 
in ego's relative subsector. 

Much of the demonstrated change in the nature of the 
relationship between ego and his network can be accounted 
for by the more inclusive approach to linkage measure taken 
at Time 1. As outlined in Chapter Five, at Time 1 linkage 
measurement took into account past services rendered by ego 
to network members in an effort to include the "carry over" 
obligation dimension of exchanges in the analysis of the 
relationship between ACLF entry and reciprocity (Gouldner, 
1960) . Thus, even if ego was not currently doing for a net- 
work member in any of the measured areas, if ego had 
rendered personal assistance to alter in the past a link 
from ego to alter was counted. 



190 



Table 10-3 



Mean after ACLF material linkage differences 
by type of network 



Total 
(N = 71) 



Relative 
(N = 69) 



Nonrelative 
(N = 54) 



-.34** 



-.34** 



-.40* 



*p < .0001. 
**p < .0005. 



Table 10-4. 



Type of material links after ACLF entry by type 
of network (N = 72) 







Network 




Material Link 


Total 


Relative 


Nonrelative 


Dependent 

Reciprocal 

Instrumental 


4.9 
2.3 

.1 


4.0 
1.8 

.1 


.8 
.4 
.0 



191 

The focus at Time 2 was only on exchanges that had 
occurred between ego and network members since the ACLF 
move. If ego was only linked to alter on the basis of 
services rendered to alter in the past, this link would no 
longer be counted. Thus, a reciprocal link would be 
redefined as a dependent link and an instrumental link would 
then be broken. 

Changes in the nature of network linkages with ego 

after ACLF entry may also be due to ego's role redefinition 

by network members. Qualitatively derived data indicate 

that with the move network members commonly redefine their 

expectations of ego, excusing him/her from behaviors that 

had been expected in the past. A primary past obligation 

that is "let go" is that of gift giving. Yet, although ego 

is no longer expected to give network members gifts, gifts 

are frequently still given to ego. Thus, what had been a 

reciprocated link becomes a dependent one. This is well 

illustrated in the following comments by alter: 

She doesn't buy gifts anymore. Before she moved 
in, I used to do that. ... It didn't mean much 
anyway, because it was from me. (a daughter) 

This was a good time to quit that. . . . Her 
son talked her out of buying gifts anymore since 
she moved into the ACLF. (a stepdaughter) 

In conclusion, while both the new residents and their 

significant others are generally quite satisfied with the 

physical and emotional care ego is receiving at the ACLF, 

directions for improvement did emerge. In the area of 



192 



maintaining ego's network relationships after ACLF entry, 
particular attention is needed in facilitating resident 
telephone accessibility and continued resident contact with 
nonrelative close others. Additionally, if one assumes that 
reciprocity in our relationships positively contributes to 
our well being and acts as a force for perpetuating those 
relationships (Gouldner, 1960; Horowitz and Shindelman, 
1983; Wentowski, 1981), an effort is also needed in facili- 
tating exchanges fxojD the resident io. his/her network mem- 
bers. Finally, increased ACLF contact with health profes- 
sionals as sources of continuing education for managers and 
staff as well as providers of on site health care management 
would serve both to upgrade ego's level of care and to ease 
some of the pressure ego's network experiences in spite of 
ego's ACLF entry. The trained eye of an outsider would also 
be useful in identifying specific strategies for ACLF's to 
modify their internal environments to meet the informal 
network tie continuity and personal control needs of their 
residents. 



CHAPTER ELEVEN 
NETWORK VARIABLES AS PREDICTORS OF TIE DURATION 
AND RETURNING HOME 



Each of the network variables — reciprocity, density, 
degree, and intensity — were analyzed to determine if their 
hypothesized effects on tie duration and returning home had 
occurred. As in the analysis of network variables as pre- 
dictors of ACLF entry, ego's total personal network and 
relative and nonrelative close others subsectors were consi- 
dered the focal networks of the analysis. Additionally, 
given the importance of ego's continued contact with his/her 
closest other, the effect of network variables on the dura- 
tion of this tie was also analyzed. 

Once again, both subjective and objective measures of 
reciprocity were considered, and to avoid the problem of 
multicollinearity between these measures their influence on 
tie duration and returning home were analyzed separately. 
Similarly, the connectivity measures of density and degree 
were also analyzed separately to determine their effects on 
the dependent variables, minimizing any multicollinearity 
effects. 

Sample size was limited due to respondent death 
(n = 6) , respondent refusal (n = 1) and the definitional 
restrictions of density and degree. The effect of this 



193 



194 

latter restriction varied according to the focal network 
being analyzed, with 4 omitted from the total network analy- 
sis, 7 from the relative network analysis, and 43 from the 
nonrelative network analysis. Further restrictions in 
sample size occurred in the analysis when alter was the 
primary data source and lacked knowledge of time two contact 
patterns with ego (n = 3) . This resulted in a possible 67 
observations for the total network analysis and the analysis 
of closest other tie duration, 64 observations for the 
relative network analysis, and only 32 observations for the 
nonrelative network analysis. Additionally, when mental 
health was the controlling health variable the sample size 
became smaller as the mental health measurement instrument 
requires direct interviewer contact with ego, and ego was 
not always available for interviewing (n = 5) . Unfortu- 
nately, the resultant small number of observations of non- 
relative network variables prohibited a meaningful analysis 
of their effects on returning home. However, the sample 
size was adequate to analyze the effects of ego's nonrela- 
tive network on tie duration. 

Returning Home 
As was discussed in Chapter Eleven, the "problem of 
return" was not inherent in ACLF entry. Sixteen percent of 
those who had entered the ACLF during the summer of 1985 had 
returned either to their home (n = 4) or to the home of a 



195 

relative (n = 8) . In an attempt to explain this phenomenon, 
logistic regression was used to regress returning home on 
the network variables reciprocity, intensity, density, and 
degree at the time of ACLF entry, with the probability of 
remaining in an institution indicated by Y = 1. As these 
exogenous variables are not serial, the problems related to 
multicollinearity, autocorrelation, and degrees of freedom 
in time-lagged variables discussed in Ostrum (1978) did not 
need to be addressed. Controls were added for ego's physi- 
cal and mental health at Time 2, as well as ego's race 
(whites coded 0, nonwhites coded 1), sex (males coded 0, 
females coded 1) , and socioeconomic status (private payer 
coded 0, state payer coded 1). Ego's physical and mental 
health at Time 2 were analyzed separately, minimizing the 
effects of multicollinearity. However, due to the nonvari- 
able effects of mental health on going home (i.e., all of 
those who went home were assessed as mentally competent with 
Pfeiffer's Short Portable Mental Status Questionnaire), only 
the control of physical health remained in the analysis. 

The resultant sets of equations are presented in 
Appendix K, Table K-l. In terms of the hypothesized rela- 
tionships, the intensity of ego's ties with his/her personal 
network at the time of the move into the ACLF was the only 
network variable that was significantly related to reloca- 
tion home at Time 2. There was no relationship with the 



196 

connectivity or the directionality of network ties at Time 1 
and relocation regardless of the indicator used. 

The higher the intensity, i.e., the emotional bonded- 
ness, of ego's ties with his/her total personal network at 
the time of the move into the ACLF the Iqm&L was the likeli- 
hood of ego returning home by Time 2 (p < .05). However, 
this relationship did not remain significant when ego's 
relative network was analyzed. Thus, once again, it is the 
way ego's network functions as a unit that is important in 
explaining the process of moving into an ACLF. 

As these results emerged controlling for ego's physical 
health at Time 2, they indicate that given residents are of 
the same self-help level, those that are less emotionally 
bonded to their networks are more likely to return home. 
This is contrary to what was predicted, and is in opposition 
to the findings of Allison-Cooke (1982), Greenley (1972), 
and Wan and Weissert (1981) (see Chapter Four). However, an 
explanation may be found in network theory. Given that high 
network emotional bondedness to ego functions to delay ego's 
move into the ACLF until ego's environmental fit is ex- 
tremely problematic, if ego is highly bonded to all of 
his/her primary network members, once ego does move into an 
ACLF it is likely that ego will not return home. 

Alternatively, if ego is not highly emotionally bonded 
to all of his/her primary network members, ACLF entry may 
have been premature, with ego, a caring network member, or a 



197 



health professional determining after entry that ego is not 
yet ready for this level of care and then relocating ego 
into ego's home or that of a relative. A lower level of 
total network bondedness may also have precipitated the use 
of an ACLF as a temporary caring institution in response to 
an acute illness acquired by ego due to the unavailability 
of network members to perform this function. Or, if ego is 
relying on only a few network members to provide for his/her 
needs, with other network members not caring enough to help, 
the ACLF may be used to give these close others some relief. 
In each of these cases, returning home would then be more 
likely. These situations did occur and are discussed in 
greater detail in Chapter Ten. Given the precariousness of 
ego's network relationships, the assistance of a profes- 
sional may ease ego's transition home. 

An explanation for the unconfirmed relationship between 
returning home and the network variables — reciprocity, de- 
gree, and density — is also found in the hypothesized rela- 
tionship between the network variables and the process of 
ACLF entry. According to network theory, along with high 
network emotional bondedness and degree, high network den- 
sity, and high tie reciprocity function to delay ACLF entry 
until ego's lack of fit is extremely problematic. Thus, if 
ego comes from one of these "stronger" networks, quite a bit 
of regrouping is likely to be necessary to make it possible 



198 

for ego to return home. Although these networks may be 
willing, they may be unable to do so. Alternatively, while 
"weaker" networks may have less accommodating to do, they 
may be unwilling to do so. The result would be what was in 
fact observed, no difference in returning home by these 
indicators of network strength. 

Results presented in Chapter Nine give some support for 
these hypotheses as density, and significant other intensity 
were directly related to the severity of ego's presenting 
health (which to some degree indicates the degree of accom- 
modation tolerated by ego's network before ACLF entry). 
Although this relationship was not consistent with degree, 
network bondedness, and reciprocity, as was discussed in 
Chapter Nine, this is not sufficient evidence to dispute the 
proposed relationship between stronger networks and delayed 
ACLF entry. Rather, these variables may be more susceptible 
to the strain of caring for an aging network member. Hence, 
by the time of entry, differences in these delaying forces 
by ego's presenting health severity may have been erased. 

In terms of the control variables, ego's health was of 
central importance in explaining going home, with ego's race 
and socioeconomic status also useful in explaining ego's 
location at Time 2 (see Table 11-1) . The more independent 
ego was in the activities of daily living at Time 2, the 
more likely ego was to have returned home. Similarly, all 
of those who had returned home by Time 2 were assessed at 



199 



Table 11-1. Effects of ego's total network on staying in an 
institution, standardized regression 
coefficients (N = 70) 



Total Network 

Variable Name B SD 

Density, Time 1 

Closest other intensity, Time 1 

Reciprocity — "objective," Time 1 

Network bondedness, Time 1 

Sex 

Socioeconomic status 

Physical health, Time 2 

Race 

*p < .05. 



1.82 


.03 


.29 


.17 


.92 


1.89 


3.25* 


.18 


-.08 


1.17 


-3.97* 


1.86 


12.64* 


1.14 


-4.26* 


1.86 



200 

Pfeiffer's highest level of mental competence. Thus, while 
contingencies are important in explaining ego's location at 
Time 2, the magnitude of the importance of ego's health in 
explaining this phase of the institutionalization process is 
encouraging. The "problem of return" does not seem to be 
inherent in ACLF entry, suggesting either that this illness 
career is measurably different than that of those institu- 
tionalized with mental health problems (Goffman, 1961; 
Greenley, 1972; Scheff, 1966) or rendering support to the 
hypotheses that while the process of institutionalization is 
influenced by social and cultural variables, the "objective" 
health state of an individual is of more primary importance 
(Gove, 1976; Gove and Fain, 1973; Gove and Howell, 1974). 
The relationship between race and returning home was 
positive, with nonwhites more likely to return home than 
whites. This finding may be explained both by different 
cultural expectations between nonwhites and whites to care 
for their elderly at home and in network theory. Assuming 
normative pressures to care for the elderly members of one's 
personal network are stronger for nonwhites (Wylie, 1981) 
and, given that nonwhite new residents are more "tightly 
glued" to their networks emotionally and structurally (see 
Chapter Seven) , it follows that the networks of nonwhites 
would facilitate the dispersion of group pressure of the 
normative value to return ego home. Thus, while network 
connectivity was not related to return home, the proposed 



201 



combination of network connectivity and normative pressure 
as indicated by nonwhites was a significant predictor of 
returning home. 

While the effect of socioeconomic status on returning 
home was only significant in the analysis of the effect of 
ego's total network on returning home, the trend did remain 
in the regression of relative network variables. Private 
payers were more likely to return home than those whose care 
was financed by the state. This finding indicates that, 
while ego's socioeconomic status was not related to ego's 
presenting health status, controlling for ego's health, and 
social network variables, money still remains an important 
factor explaining the process of institutionalizing the 
elderly. When either ego or ego's network was paying for 
ego's care, ego was more likely to return home. 

In conclusion, if ego were highly emotionally bonded to 
his/her network at the time of the move into the ACLF, and 
ego is white, of poorer health status, and has arranged to 
have his/her care financed by the state, then ego is more 
likely to remain in an institutionalized setting after ACLF 
entry has occurred. Alternatively, those residents who are 
most likely to return home are in better physical and mental 
health, nonwhite, have been paying for their care them- 
selves, or with the help of their network, and were less 
emotionally bonded to their network at the time of ACLF 



202 

entry. Thus, in addition to ego's health status, ego's 
network bondedness, ability to pay for care, and race also 
play a significant role in orchestrating his/her illness 
career. These relationships are illustrated in Figure 11-1 



Network emotional 
bondedness 



SES (state-rate) 
Race (nonwhite) 
Health at Time 2 




^ Returning 
home 



Figure 11-1. Variable effects on returning home 

Note: Reciprocity, density, degree, closest other 

intensity, and sex are omitted as they were not 
significant at p < .05. 



Tie Duration 
As discussed in Chapter Ten, moving into the ACLF 
resulted in highly significant decreases in ego's primary 
network tie duration as measured both by the frequency of 
ego's network contacts and by the number of material links 
connecting ego and network members. This decrease was ex- 
pected. The focus in this chapter is on the degree to which 
morphological and interactional network variables explain 
tie duration decreases between ego and network members after 
the move into the ACLF. 



203 



It was hypothesized that tie duration would be directly 
related to the density, degree, reciprocity, and intensity 
of ego's network ties net of the pattern of contact 
(visiting, speaking, and writing) and material linkages 
between ego and his/her network during the year prior to the 
move into the ACLF. Thus, Time 1 measures of tie duration 
were controlled for by utilizing a multiple regression anal- 
ysis and entering them in the equation as the first indepen- 
dent variable. However, it was recognized that due to the 
problem of autocorrelation between the error term and Time 1 
contact, the influence of Time 1 contact on tie duration 
would probably be biased upward (Ostrom, 1978) . Controls 
were also added for ego's sex, race, socioeconomic status 
(females, nonwhites, and state payers were coded 1, and 
males, whites, and private payers were coded 0) and ego's 
level of physical and mental health at Time 2 due to the be- 
tween-group differences on these variables outlined in 
Chapter Seven. As with the reciprocity and connectivity 
measures, physical and mental health effects were analyzed 
separately to minimize any multicollinearity effects. 
Additionally, ego's location at Time 2 was taken into ac- 
count by controlling for whether ego had returned home 
(coded 0) or remained in an ACLF or nursing home (coded 1) . 



204 

Contact Frequency 

The effect of network variables differed by focal net- 
work and the type of contact being analyzed. The density of 
ego's total primary network, the density of his/her relative 
subsector, and the proportion of reciprocated links in ego's 
relative subsector, as well as the control variables — ego's 
location at Time 2, ego's mental health at Time 2, and Time 

1 contact levels — all were significantly related to ego's 
total primary network and relative subsector 's frequency of 
visiting and speaking with ego at follow-up. There was no 
relationship with total primary network and relative 
visiting or speaking contact frequency at follow-up and 
network intensity, degree, or the subjective measure of 
reciprocity, nor with the control variables — sex, race, 
socioeconomic status, and ego's level of physical health at 
Time 2 (p >. 05) . Alternatively, none of the network var- 
iables explained nonrelative visiting and speaking at Time 
2. The significant variables for this subsector were the 
controls. Time 1 contact levels, and ego's location at Time 

2 each helped explain nonrelative visiting and speaking 
contact at Time 2 (see Appendix K, Table K-2) . 

In terms of written contact, for ego's total and rela- 
tive networks by far the greatest percentage in the variance 
in Time 2 contact levels was explained by Time 1 levels, the 
only other significant variable being reciprocity, with both 
objective and subjective measures significant. 



205 



Alternatively, for ego's nonrelative sector, network vari- 
ables and the remaining controls explain a greater per- 
centage of the variance in Time 2 writing contact levels 
than do Time 1 levels. Once again, both indicators of 
reciprocity are the only other significant variables, but 
this time the level of significance of objective reciprocity 
jumps to p < .005 (see Appendix K, Table K-2) . 

These differences in variable effects on Time 2 contact 
by type of contact and focal network are further illustrated 
by examining equation differences in R-square values. As a 
unit, relative network variables along with the controls 
explained the highest percentage of variation in Time 2 
visiting. Alternatively, for nonrelatives, the highest 
percentage in the variance of contact at Time 2 was ex- 
plained for writing, with network variables and controls 
least useful in explaining visiting. 

An explanation for these results can be found in the 
utilization of ACLF proximity to relatives' work sites or 
homes as a primary selection criteria. While this 
facilitates continued relative visiting, it limits continued 
visiting by nonrelative close others. While this would not 
affect telephone contact, as is discussed in Chapter Ten, 
there are multiple within-site factors that serve to limit 
telephone contact with ego by both relatives and nonrela- 
tives. Thus, nonrelatives may find it easiest to stay in 



206 



contact with ego by writing and relatives may find it most 
convenient to visit. The differential explanatory power of 
the independent variables on the different types of contact 
by focal network, then, may indicate that network variables 
have their greatest influence on the contact patterns of 
least resistance for the network being focused upon. 

With the exception of Time 1 nonrelative speaking, each 
of the Time 1 contact frequency scores was significantly 
related to the Time 2 level of that variable. This may be 
explained, in part, by the classic problem of omitted vari- 
ables. As Time 1 contact levels are correlated with the 
error term, the coefficient estimate of Time 1 contact 
levels will reflect some of the influence of any overlooked 
variables that help explain tie duration (Ostrom, 1978). As 
Time 2 contact frequency levels generally were significantly 
lower than Time 1 levels (see the discussion in Chapter 
Ten) , this indicates that the level of that decline is 
predictable by the network's level of contact with ego prior 
to ACLF entry. Additionally, as is indicated in Appendix K, 
Table K-2, Time 1 contact frequency levels explained a 
relatively high percentage of the variability in Time 2 
contact frequency. 

As mentioned earlier, this was especially true for the 
effect of Time 1 total and relative writing on Time 2 
writing levels. Only approximately 9% of total Time 2 
writing and 11% of relative Time 2 writing were explained by 



207 



the independent variables net of Time 1 writing levels. 
This finding is consistent with results of the t-tests 
reported in Chapter Ten, which indicate that unlike visiting 
and speaking patterns, there is little change in network 
writing patterns with ego after ACLF entry. 

As indicated by the standardized beta weights (see 
Table 11-2) , along with Time 1 levels of total and relative 
visiting and speaking, density is the best single predictor 
of Time 2 total and relative visiting and speaking. This 
relationship is in the predicted positive direction. The 
higher the density of ego's total primary network and rela- 
tive subsector, the greater was ego's visiting and speaking 
contact with that network at Time 2. Thus, the role of 
density in the process of institutionalization is primary, 
both in determining ego's level of health at the time of 
ACLF entry and in determining the degree to which network 
members remain in contact with ego after entry occurs. 

The fact that density was not useful in explaining 
nonrelative Time 2 visiting or speaking may in part be 
explained by the smaller sample size available for this 
analysis. Additionally, this finding lends further support 
to the contention that the barriers associated with ACLF 
entry are sufficient enough to negate the tie continuity 
facilitating effects of ego's nonrelative network. 



208 



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210 

Similarly, nonstandardized regression coefficients in- 
dicate that, while density explains both Time 2 total and 
relative visiting and speaking, its influence on visiting is 
consistently greater (see Appendix K, Table K-2) . This may 
be understood by reviewing the findings in Chapter Ten on 
the structural barriers imposed by the ACLF and the effect 
of ego's declining health on telephone utilization by resi- 
dents and their networks. It seems that negative effects of 
the place also act to limit the speaking tie duration moti- 
vating force of network density, resulting in finding den- 
sity to have a lesser effect on Time 2 speaking than 
visiting contact between ego and network members after ACLF 
entry. 

The fact that density and not degree explained tie 
duration after ACLF (see Appendix K, Table K-2) entry led 
this researcher to focus her analysis on the regression 
equations with density as the connectivity indicator. This 
finding reinforces the difference between these two indica- 
tors of network connectivity which has been demonstrated 
throughout this dissertation. While density is the propor- 
tion of theoretically possible links — and thus reflects the 
tightness of fit in a network, degree is the average number 
of relationships networks have with each other, thereby 
reflecting more of a scope dimension of connectivity. 

Based on these results, one would say that the 
tightness of fit of one's network rather than the magnitude 



211 



of network ties held by network members is important in 
explaining tie duration after a potentially separating 
event. Other studies on the network effects of help-seeking 
behavior and tie duration have generally focused on density 
as the indicator of network connectivity (Hammer, 1963; 
Horwitz, 1977; McKinlay, 1973; Perrucci and Targ f 1982). By 
clearly differentiating the explanatory power of these two 
variable indicators, this study makes a useful contribution 
to current network research and theory. 

The finding that density and not intensity was shown to 
explain contact frequency at Time 2 runs counter to "common 
sense hunches" about the effect of caring on tie duration. 
Rather, further support is demonstrated for the proposition 
in network theory that states that it is the structural 
support of one's network, i.e., the percentage of possible 
intranetwork connections realized, rather than the content 
of those connections that is most likely to affect the 
likelihood of a relationship being maintained or severed 
(Granovetter, 1973, 1981; Hammer, 1963, 1981). 

Both indicators of reciprocity were found to be related 
to contact frequency. Perceived balance only explained 
writing, with a positive relationship emerging across all 
three focal networks (p < .05). Alternatively, the rela- 
tionship between the "objective" measure of tie reciprocity 
and contact frequency is mixed. The proportion of 



212 

reciprocated links was positively related to relative 
visiting (p < .05) and to nonrelative writing at Time 2 
(p < .01) . However, there was a tendency for the proportion 
of relative reciprocated links, to vary inversely with the 
frequency of relative writing at Time 2. 

The effect of reciprocity indicates that the more ego 
was able to maintain a balanced give and take relationship 
with relatives prior to ACLF entry, the higher was the 
frequency of relative visiting after ACLF entry occurred. 
Possibly, as has been theorized by Gouldner (1960) , Horowitz 
and Shindelman (1983) , and Wentowski (1981) , these relatives 
were less likely to feel like they had already done more 
than their fair share. Hence, they expended the required 
effort to maintain visiting contact with ego after ACLF 
entry. Alternatively, the past efforts of ego toward net- 
work members may act to obligate network members to continue 
to "do for" ego by maintaining contact with him/her. Sim- 
ilarly, while visiting and speaking contact by nonrelative 
close others may be prohibitively difficult, continued writ- 
ten contact by this subnetwork may be facilitated by the 
fact that up to the time of ACLF entry, ego had maintained a 
relatively balanced relationship with them. However, it 
should be noted that although this may be the easiest way 
for nonrelatives to stay in contact with ego, its frequency 
of use is low (see Chapter Ten) . 



213 

In terms of the control variables, while remaining in 
an institutionalized setting did tend to be negatively re- 
lated to ego's contact with network members at Time 2, the 
relationship was not consistently significant across type of 
contact and the different focal networks. Remaining in an 
institutionalized setting was negatively related to visiting 
contact by ego's total network, regardless of whether one 
controls for ego's self-care ability at Time 2 (p < .01) or 
ego's mental health (p < .05). However, the relationship 
with location at follow-up and the mean frequency of ego's 
total primary network speaking contact was only demonstrated 
when controlling for ego's self care ability (p < .05). 
This relationship was no longer evident when ego's mental 
health was controlled for. Given that unlike physical 
health at Time 2, ego's mental health is a significant 
predictor of total network speaking frequency, the relation- 
ship with speaking and location may be spurious. 

In terms of relative visiting and speaking contact 
after ACLF entry, those that had remained in an institu- 
tionalized setting were visited and spoken with by relatives 
on average just as often as those who returned home, regard- 
less of the controlling health variable included in the 
analysis. For nonrelatives, location was only useful in 
explaining speaking at Time 2. Those remaining in the ACLF 
were in less speaking contact with nonrelatives than those 
who returned home (p < .05) . 



214 



Thus, those that remain in the ACLF are not in that 
much less contact with their network than those who return 
home. This is surprising, and at least at first glance, 
encouraging. However, as the t-test findings discussed in 
Chapter Eleven revealed that only relative visiting does not 
decline significantly after ACLF, entry one cannot conclude 
that moving into an ACLF does not negatively affect contact 
frequency. 

Rather, the probable explanation for these findings can 
be found from the regression on returning home. Those who 
return home tend to come from networks to which they are 
less intensely bonded. Finding that respondents who return 
home are so infrequently in visiting and speaking contact 
with their primary network members upon their return home 
that they often have no more network contacts than those who 
have remained in an institutionalized setting, then, is 
another indicator of the low degree of interactional network 
supportedness experienced by those respondents that returned 
home. 

In terms of the other control variables, the delineated 
pattern of network contact at follow-up was different than 
the network contact pattern with ego prior to ACLF entry for 
race, sex and mental health. Only socioeconomic status and 
physical health retained the same effect on network contact 
after ACLF entry (see Appendix I and Appendix K, Table K-2) . 






215 

Nonwhites were in more frequent visiting and speaking con- 
tact with relatives and more frequent speaking contact with 
their total primary network prior to their move. However, 
after ACLF entry, the effect of race became generally in- 
significant, with nonwhites tending to be in less frequent 
visiting and speaking contact with ego. This suggests, as 
does Mutran's study (1985), the difficulty of separating the 
effects of culture from social structure. 

Similarly, while males had been in more frequent 
visiting contact with their total primary network and in 
more frequent visiting and speaking contact with their rela- 
tive subsector prior to ACLF entry, after their move these 
differences were no longer significant. In terms of ego's 
mental health, prior to ACLF entry poorer mental health was 
associated with less written contact with ego's total per- 
sonal network and with his/her relative subsector, and a 
greater number of visits with relatives. After the move, 
there was no longer any difference in network written com- 
munication or in frequency of relative visits and speaking 
contact with ego's total primary network became negatively 
related to ego's mental health (p < .05). Thus, it seems 
that the structural barriers associated with ACLF entry were 
more limiting on network contact with ego for nonwhites and 
males, and for the networks of residents with a poorer 
mental health status. 



216 

Closest Other Contact Frequency 

The focus of the analysis of closest other contact 
frequency was on the relationship of total primary and 
relative and nonrelative subsector network variables to 
ego's visiting and speaking contact with his/her closest 
other after ACLF entry. It was hypothesized that closest 
other tie duration would also be directly related to the 
density, degree, intensity, and reciprocity of ego's network 
ties net of the pattern of closest other visiting and 
speaking prior to the move into the ACLF. Thus, as with the 
analysis of network tie duration, Time 1 levels of speaking 
and visiting were controlled for by utilizing a multiple 
regression analysis and entering them in the equation as the 
first independent variables. As before, controls were added 
for sex, race, socioeconomic status, physical health, and 
mental health. The additional control of marital status 
(married was coded and nonmarried coded 1) was also in- 
cluded for this analysis. 

In addition to explaining total primary and relative 
tie duration, the network variables density and reciprocity 
are also positively related to closest other contact fre- 
quency. However, in this analysis only the objective indi- 
cator of reciprocity was a useful explanatory variable. 
Perceived balance was not significant. The effects of in- 
tensity and degree on contact frequency at time two were 
also not significant (p > .05) . While none of the controls 



217 



were consistently significant across the different equa- 
tions, Time 1 closest other contact levels, as well as race, 
marital status, and location all had some power in ex- 
plaining Time 2 closest other contact frequency. 

As degree and perceived balance were not useful in ex- 
plaining closest other contact frequency, the remainder of 
this analysis follows the strategy used in the analysis of 
network contact frequency and focuses on the more powerful 
regression equations, which in this case have density as the 
connectivity indicator and the "objective" measure of reci- 
procity. Additionally, as in this analysis neither health 
indicator is significant, to facilitate comparisons with the 
analysis of network contact frequency, the researcher 
elected to focus on the equations with mental health as the 
controlling health variable. These results are presented in 
Appendix K, Table K-3. 

As in the analysis of the effect of network variables 
on ego's network contact frequency, the effect of network 
variables also varied by the social network and the type of 
contact being analyzed. A comparison of the effects of 
network variables on closest other contact by focal network 
quantitatively substantiates some of the comments by closest 
others documented in Chapter Ten on the important supportive 
role played by ego's nonrelative network members. The re- 
gression with nonrelative network variables explained almost 



218 

twice the variance in closest other visiting and nearly 
three times the variance in closest other speaking than did 
total or relative network variables (see Appendix K, Table 
K-3) . As discussed earlier, while lack of transportation 
may make visiting by nonrelative members difficult they may 
continue to express their bondedness to ego by caring for 
ego's closest other, supporting this person's continual 
efforts to stay in contact with ego. These results indicate 
that this effort makes a considerable difference in the 
degree to which ego's closest other remains in contact with 
ego. 

A comparison of variable effects by type of contact 
indicates that the variables as a unit explain a higher 
percentage of the variance in closest other visiting than in 
closest other speaking. This is most dramatically indicated 
in the analysis using total and relative variables, as the 
R-square for visiting is 1.50 times that for speaking. 
Given that ego's closest other generally was a relative 
(78%) , it is not surprising that in many ways these findings 
parallel those found in Time 2 relative contacts with ego. 
Once again, an explanation for this phenomenon can be found 
in the multiple structural barriers in the ACLF environment 
which act to limit continued phone utilization by ego. This 
decreases the tie continuity potentiating forces of "strong 
networks" for speaking communication. 



219 

Returning to the individual variable effects, with the 
exception of the regression of Time 2 closest other contact 
on the nonrelative network variables, each of the Time 1 
closest other contact levels was related to Time 2 contact 
levels. In fact, while the model as a unit explained most 
of the variance in Time 2 visiting, Time 1 closest other 
speaking accounted for almost all of the variance in Time 2 
closest other speaking (see Appendix K, Table K-3) . As 
closest other visiting and speaking contact do decline after 
ACLF entry, the level of these declines can then, at least 
in part, be explained by the prior level of contact. 

As before, the direct relationship between Time 2 
visiting contact and network density is strong for ego's 
total primary and relative networks (see Table 11-3 and 
Appendix K, Table K-3). This leads to the conclusion that 
network density affects both the tie duration of the network 
as a group and the duration of the ties with whom ego holds 
the closest bonds. Further support is thus added to the 
hypothesized direct relationship of density to tie duration. 

In fact, while nonrelative network density did not 
explain nonrelative visiting, in this analysis the effect of 
density holds for all three networks. The higher the 
density of ego's nonrelative network, the more frequently 
ego's closest other visited ego after ACLF entry (p < .10). 
In addition to supporting the hypothesized relationship 
between density and tie duration, this finding adds further 



220 



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222 

support for the hypothesized supportive, indirect role of 
nonrelatives on continued network contact with ego after 
ACLF entry. 

The relationship between network density and closest 
other speaking frequency after ACLF entry is not as clear. 
Only relative density has an effect on this variable 
(p < .05) . Additionally, when total and relative network 
variables are regressed on Time 2 contact, nonstandardized 
regression coefficients indicate that the effect of density 
is consistently greater on Time 2 visiting than on Time 2 
speaking for each of the focal networks (see Appendix K, 
Table K-3) . Again, these findings are explained by the 
relative difficulty of phone contact with ego after ACLF 
entry, suggesting that network variables have their greatest 
effects on the paths of communication with the least resis- 
tance. 

The relationship between reciprocity and closest other 
contact frequency is also in the predicted direction; the 
higher the degree of reciprocity in ego's network ties 
at the time of ACLF entry, the more likely closest other 
ties were to endure. The effect of reciprocity on visiting 
was demonstrated for all three focal networks, with the 
greatest effect emerging for the proportion of reciprocal 
links in ego's nonrelative network (see Appendix K, 
Table K-3) . 



223 

This means that the more ego was able to maintain an 
even give and take with his/her primary network, particu- 
larly with nonrelative network members, prior to ACLF entry, 
the higher was the frequency of visiting by ego's closest 
other after ACLF entry. As discussed earlier, tie recipro- 
city may act to encourage network members to continue to do 
for ego. Maintaining contact with ego is a principal way of 
expressing this function. Given that reciprocity explained 
contact frequency by ego's network as a unit, it is not 
surprising that the network member that ego is closest to 
also is affected by the reciprocity "push," thereby main- 
taining contact with ego after the move. 

Furthermore, as was proposed with the discussion of the 
findings on density, the network unit may indirectly express 
their desire to continue to do for ego by supporting ego's 
closest other's attempts to maintain contact with ego after 
the move rather than by personally continuing to visit ego. 
This is particularly indicated both by the large effect of 
nonrelative reciprocity on tie duration as well as qualita- 
tive data from interviews with ego's closest others. 

As with density, reciprocity had a much lower effect on 
speaking. Only when the effect of reciprocity of ego's 
nonrelative network is regressed on Time 2 closest other 
speaking does a significant relationship emerge between 
reciprocity and speaking. Thus, this too, serves to 



224 

emphasize the difficulty of maintaining phone contact with 
ego after ACLF entry. 

The lack of significance of perceived balance on clos- 
est other visiting and speaking frequencies is consistent 
with the findings in the analysis of the frequency of net- 
work contact patterns. Only written contact was explained 
by perceived balance; speaking and visiting were not. As 
discussed earlier, it is not surprising that these two 
indicators differentially explain tie duration. While sub- 
jective reciprocity includes both emotional and material 
dimensions, "objective" reciprocity only takes into account 
the material give and take balance. These findings, then, 
coupled with finding that neither the intensity of ego's 
closest other relationship nor the intensity of ego's net- 
work relationships explained closest other contact frequency 
indicate that the balance of material links has a greater 
effect on tie duration after ACLF entry than does the inten- 
sity of emotional relationships. 

In terms of the control variables, the effect of race 
(p < .05) and marital status (p < .10) was limited to the 
analysis of nonrelative network variables. This is a select 
subsample of the study (N = 32). Thus, only for those new 
residents with at least two nonrelative close others do race 
and marital status make a difference on Time 2 contact, with 
Time 2 closest other contact greater if ego is nonwhite and 
married. In this case nonwhites are able to overcome any 



225 



extra contact barriers they may be faced with and continue 
to be in more visiting contact with the resident than 
whites, as they were before ACLF entry. 

Location also explained contact frequency, with those 
who remained in an institution in tending to be in more 
contact with their closest other than those who returned 
home (p < .10). This relationship was contrary to what was 
expected. Yet, it does support other study results that 
point toward weakness in the networks of those returning 
home. As this result was present in the analysis of rela- 
tive as well as nonrelative variables its effect is more 
generalizable than the findings on race and marital status. 

Material Links 

The alternative indicator, network material linkages at 
Time 2, was also used to analyze changes in tie duration 
after ACLF entry. This approach focuses on the maintenance 
of tie content rather than on the frequency of interaction 
between ego and network members. As it is generally more 
difficult for network members to continue to exchange ser- 
vices with ego than for them to remain in contact with ego, 
Time 2 material linkages is a more restrictive measure of 
tie duration. 

Thus, finding that the proportion of variance in Time 2 
material links explained by the regression analysis was 
generally less than that explained by the regression of the 



226 



different types of Time 2 network contact levels with ego is 
not surprising (see Appendix K f Tables K-2 and K-4) . Unlike 
with contact frequency, net of Time 1 mean number of mate- 
rial links, neither network nor control variables were very 
useful in explaining the mean number of network material 
links with ego at Time 2. While density continued to tend 
to be positively related to Time 2 level of material network 
linkages, neither intensity, reciprocity, nor degree had any 
explanatory value. As for the controls, while neither phy- 
sical or mental health status, nor sex explained Time 2 
level of material linkages with ego, remaining in the ACLF 
continued to tend to be negatively associated with tie 
duration (p < .10) . Additionally, whites and state-financed 
residents maintained more material linkages with their net- 
work than did nonwhites and private payers. 

As degree was not useful in explaining Time 2 material 
links, the remainder of this analysis also focuses on the 
regressions of Time 2 material links with density as the 
connectivity indicator. Additionally, given that in this 
instance neither reciprocity nor health indicator had 
significant effects on Time 2 material links, to facilitate 
comparisons between the regressions on the two different 
measures of tie duration, the researcher also elected to 
focus on the equations that had included mental health as 
the controlling health variable and the objective measure of 



227 

reciprocity. These results are presented in Appendix K, 
Table K-4. 

Time 1 total and relative network material links are 
significantly related to Time 2 levels of material linkages. 
As Time 2 levels were significantly lower than Time 1 levels 
(see the discussion in Chapter Ten) , this indicates that the 
level of decline is predictable by the networks prior level 
of material links with ego. However, this did not hold for 
ego's nonrelative subsector. Time 1 levels did not explain 
levels of material links at Time 2, once again suggesting 
that ACLF entry poses significant tie maintenance barriers 
for ego's nonrelative network. 

Although the effect of density on network material 
linkages at Time 2 is less than its effect on network 
visiting and speaking contact frequency at Time 2 (see 
Appendix K, Tables K-2 and K-4) , a positive tendency remains 
in spite of the greater restrictiveness of the indicator 
used in this portion of the analysis (p < .10) . Thus, 
further support is lent to the study hypothesis: 

Tie duration is a positive function of network density. 

The finding that density is the only network variable 
that explains Time 2 material links is explained by the 
influence of barriers related to ACLF entry on the positive 
tie continuity effects of "strong networks." It is more 
difficult for network members to continue to exchange ser- 
vices with ego then to remain in contact with him/her after 



228 



the move. Given that the strongest predictor of contact 
duration is only a weak, albeit the best network predictor 
of linkage duration (see Table 11-4) , it follows that the 
less strong network predictor of contact duration — recipro- 
city — is not useful in explaining linkage duration. 

As for the control variables, while the finding that 
nonwhites and continued ACLF residents have less material 
linkages with ego at Time 2 is harmonious with previously 
reported study results, the positive relationship with non- 
relative material linkages and socioeconomic status is new 
(p < .05) . An optimistic interpretation would be that when 
the state had assumed the financial responsibilities for 
ego's care, ego had a more "supportive" nonrelative network. 
And although nonrelatives are not normally expected to pay 
for the needs of their close others, they did continue to 
supplement the state service by doing for ego in other ways 
after ACLF entry. 

The strong effect of being nonwhite on material linkage 
duration after ACLF entry again points to the greater con- 
tact barrier effect of the move on nonwhites than whites. In 
fact, in this case the effect of race is greater than that 
of density (see Table 11-4) . This is especially significant 
as before ACLF entry there was no objective difference in 
the size of ego's network with material linkages by race. 



229 



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230 

As for location, while remaining in an ACLF does tend 
to be negatively related to material linkage duration, this 
effect is much weaker than was expected (see Appendix K, 
Table K-4; and Table 11-4). Only when the total primary 
network is taken into account does an effect emerge, and 
this is at p < .10. This indicates that those that go home 
do not have many more material linkages with their network 
then those who remain in the ACLF. This finding is consis- 
tent with the previously reported negative association bet- 
ween going home and network emotional bondedness as well as 
the finding that going home was only selectively associated 
with more frequent network contacts with ego. Thus, in 
tandem, these results support the theorized relationship 
between negative structural and contextual network relation- 
ships and less restrictive institutional placement criteria. 

In conclusion, network variables and the controls were 
related to tie duration and returning home in eight ways. 
First, in addition to being in better health, those that 
went home were nonwhite, were paying for their care by them- 
selves or with the help of their network, and came from 
networks to which they were less emotionally bonded. Addi- 
tionally, those that returned home were only in more fre- 
quent total network visiting and nonrelative speaking con- 
tact than those who remained in the ACLF. Second, density 
emerged as the strongest and most consistent variable ex- 
plaining tie duration, with positive relationships 



231 



demonstrated for total primary and relative visiting and 
speaking, closest other visiting and speaking, and total 
primary and relative material linkage duration. Third, 
neither closest other intensity nor ego's network emotional 
bondedness levels had any effect on tie duration, further 
emphasizing the importance of density on these variables. 
Fourth, degree did not explain either tie duration or re- 
turning home, reinforcing the difference between these two 
connectivity indicators that was demonstrated earlier in the 
analysis of ACLF entry. Fifth, while both the inclusive 
subjective measure of reciprocity and the material link 
focused objective reciprocity measure were shown to affect 
tie duration (in terms of contact frequency only) , with the 
exception of writing contact the effect of a balance of 
material links was generally greater. Sixth, the influence 
of network variables was shown to be the greatest on the 
paths of least resistance for the focal network, i.e., 
visiting for relatives, and writing for nonrelatives. 
Seventh, while visiting and speaking contact was difficult 
for nonrelative members, they played a significant role in 
supporting continued visiting and speaking contact by ego's 
closest other. And finally, moving into an ACLF seems to 
present greater contact barriers for the networks of non- 
whites, males, and those mentally incompetent. These re- 
lationships are illustrated in Figures 11-1 and 11-2. 



232 



Time 1 contact 



Perceived balance 



Proportion of 
reciprocated 
network links 



Health severity 
at Time 2 



Density 



Location (ACLF) 



SES (state-rate) 



Race (nonwhite)- 




Closest other 

contact 

frequency at 

Time 2 



Network contact 

frequency at 

Time 2 



work number 

of material 

links at 

Time 2 



Network numbers of 
material links 
at Time 1 



Figure 11-2. Variable effects on tie duration 

Note: Closest other intensity, network bondedness, degree, 
marital status, and sex are omitted as they were not 
significant at p < .05. 



CHAPTER TWELVE 

CONCLUSIONS: 

THEORETICAL AND PRACTICAL IMPLICATIONS 



This research was a longitudinal study oriented toward 
understanding the effect of the elderly *s networks on the 
process by which the elderly enter and settle into ACLFs and 
continue to maintain their primary network ties. A combin- 
ation of qualitative and quantitative methodologies were 
used with both new residents and their closest others ser- 
ving as key informants. 

The initial interviews provided data on ego's health 
status, the process by which the ACLF was entered, and the 
structural and interaction characteristics of ego's network. 
Follow-up interviews determined ego's health status and 
perception of the ACLF at that time, ego's location, as well 
as the degree to which ego's ties had endured after ACLF 
entry. 

Previous chapters have examined the findings of this 
work at length. In this chapter the theoretical implica- 
tions of these results are summarized and future research 
directions are addressed. Additionally, practical implica- 
tions drawn from this research for ACLF caregivers, the 
health professionals involved in caring for ego, and ego's 
network prior to ACLF entry are outlined. 



233 



234 



Theoretical Im plications 
and Directi ons for Future Research 

Network variables were demonstrated to influence the 
process by which the elderly came to enter the ACLF, the 
degree to which they settled into this new environment, and 
the degree to which the ties residents had with their pri- 
mary network before they entered into the ACLF endured. 
Additionally, ego's race, socioeconomic status, and health 
were also significant in explaining these processes. 

Entering the ACLF 

Entering the ACLF required both that ego's current 
environmental fit be recognized as problematic and that 
moving into an ACLF be determined an appropriate response. 
Professionals played only a secondary role in these deci- 
sions. The elderly' s informal network, more specifically, 
relative primary group members were the principal source of 
problem recognition and ACLF referral. 

While it had been hypothesized that the involvement of 
either professionals or informal network members in the 
labeling and referral process would be a function of the 
density and degree of the elderly *s personal network, this 
was not supported. An explanation is found in the inappro- 
priate choice of anchors for network delimitation. As ego's 
relatives primarily made these decisions, with ego only 
rarely responsible for self-labeling or referral, the 



235 

density and degree of ego's closest other's network is more 
likely to predict the source of labeling and referral. 

Consistent with Granovetter ' s (1973, 1981) and 
Horwitz's (1977) propositions, it follows that if ego's 
closest other belongs to a low density network and, thus, is 
connected to a larger number of information channels, ego's 
closest other will be more likely to (a) have a diverse 
knowledge base and thus identify ego's condition as a prob- 
lem, and (b) be knowledgeable of ACLFs and, hence, refer ego 
to an ACLF as a response to his/her lack of fit. Future 
research in this area needs to assess the structure of the 
network of ego's closest other to enable further exploration 
of these propositions. 

The hypothesized effect of density was demonstrated for 
ego's presenting physical and mental health severity. The 
greater the density of ego's total network, (a) the greater 
the severity of ego's presenting mental health, and (b) the 
greater the severity of ego's presenting physical health. 
Relative density was directly related to ego's physical 
health only. The network variables — degree and intensity — 
were also demonstrated to influence ego's presenting health 
status, but their effects were generally secondary to that 
of density (see Chapter Nine). 

The effect of density on health care utilization pat- 
terns has been demonstrated for other population groups 
(Hammer, 1963, 1981; Horwitz, 1977; McKinlay, 1973; Perrucci 



236 



and Targ, 1982, Sokolovski et al. f 1978). However, its 
incorporation in research on the process by which the frail 
elderly move into an institution is unique to this study. 
Thus, these findings make a significant contribution to 
network theory and gerontological research. 

As discussed in Chapter Nine, reasons for these 
findings are multiple. Possibly, as theorized earlier, a 
dense network has less outside contact to assist in problem 
recognition and help seeking, which may result in a delay in 
ACLF referral until ego's health worsens. Or, alterna- 
tively, network density may be directly related to intranet- 
work supportiveness (Hammer, 1963). A dense network struc- 
ture would then facilitate intranetwork support for members 
struggling to maintain ego home. A dense network may also 
be more able to put collective pressure on its members to 
persist in these caregiving activities (Bott, 1954) . 
The researcher found the effect of density was 
greatest only when ego's total primary network was consi- 
dered. This suggests that it is the structure of this total 
unit rather than the structure of either the relative or 
nonrelative subsector taken separately which has a critical 
effect on the process of ACLF entry. While other research 
has also found that it is important to consider the way the 
elderly interact with both relative and nonrelative close 
others when studying the degree to which elderly are able to 






237 

continue to fit into their home (Cantor, 1979; Chappell, 
1983; Dono, Falbe, Kail, Litwick, Sherman, and Siegel, 1979; 
Rundall and Evashwick, 1982; Wan and Weissert, 1981; 
Wentowski, 1981), once again, this study's incorporation of 
the concept of density is a unique approach in the study of 
these questions. Thus, its contribution is significant and 
points for a continued need to focus on the effect of the 
interconnections between all of ego's primary group members 
in theory and research on the process of caring for the 
frail elderly at home and institutionalization. 

The effect of degree on ACLF entry was consistently 
shown to be different from and frequently less than that of 
density (see Chapter Nine) , demonstrating the noninter- 
changeability of these two connectivity indicators. As 
other studies on the network effects of help-seeking behav- 
ior have generally focused on density as the indicator of 
network connectivity (Hammer, 1963; Horwitz, 1977, McKinlay, 
1973, Perrucci and Targ, 1982), clearly differentiating the 
explanatory power of these two indicators is another useful 
contribution of this study to current network research and 
theory. 

Furthermore, in terms of labeling and referral, while 
the choice of anchor is inappropriate, the consistently 
negative relationship between degree and both labeling and 
referral results in a new hypothesis emerging from this 
study: As the average number of relationships network 



238 



members have with one another decreases, the probability of 
professional labeling and referral increases. 

This is directly contrary to the demonstrated rela- 
tionship between density and the source of labeling and 
referral. Increased density is hypothesized to limit ego's 
external network contact, thus restricting his/her informal 
sources of information. Alternatively, decreased degree is 
hypothesized to limit ego's available internal network con- 
tacts, thus limiting his/her sources of information. This 
later condition would then account for the negative rela- 
tionship between degree and informal sources of labeling and 
referral. As exploration of this theoretical relationship 
is limited to this study, a need remains for both more 
extensive theoretical and research-oriented study of this 
hypothesis. 

While only the structure of the elderly *s primary net- 
work was hypothesized to affect the referral process, both 
reciprocity and intensity were also theorized to affect the 
source of the elderly *s "out of place" label and the sever- 
ity of their presenting health status. Lending support to 
both network and labeling theory (Horwitz, 1977; Horowitz 
and Shindelman, 1983; Lowenthal-Fiske, 1964; McKinlay, 1973, 
Scheff, 1966) as well as providing new information on the 
applicability of these theories in the process of institu- 
tionalizing the elderly, the intensity of ego's network ties 



239 

was demonstrated to influence both the source of ego's label 
and the severity of ego's presenting health status. 

The higher the intensity of ego's network bonds, the 
more likely the source of ego's "out of place" label was a 
professional rather than an informal network member. The 
intensity of ego's total primary relationships had the 
greatest effect the source of the elderly 's "out of place" 
label, indicating that it is the combined intensity of 
ego's relative and nonrelative network relationships that is 
most critical in explaining the labeling process. If both 
of these sectors are closely bonded to ego, they are more 
likely to share a sense of willingness to "do for" ego and, 
hence, are more likely to tolerate ego's behavior and not 
label it "out of place." However, if only one sector is 
closely bonded to ego, the other may interject an "out of 
place" label on ego's behavior other than a professional and 
influence the remaining portion of ego's network to assume a 
similar attitude. 

Furthermore, no relationship between reciprocity and 
labeling emerged and the effect of reciprocity on ego's 
presenting health severity was only demonstrated at p < .10. 
Thus, only weak support for the hypothesized relationships 
was shown (Gouldner, 1960; Horowitz and Schindelman, 1983; 
Wentowski, 1981) . 

The effects of both intensity and reciprocity on ego's 
presenting health were relatively weak, and secondary to 



240 



that of density (see Chapter Nine). Two explanations are 
offered. Possibly, as suggested in Hammer (1981) , the "posi- 
tive" network structural characteristic — high density — is in 
fact a more "supportive" force than are the positive inter- 
actional characteristics, high intensity, and high recipro- 
city. Alternatively, perhaps the intensity and reciprocity 
of ego's ties are equally as important as density in de- 
laying ACLF entry. The degree of these variables may have 
been higher when network members began to attempt to accom- 
modate ego's environment to facilitate keeping him/her at 
home but, by the time of ACLF entry the initial degree of 
these characteristics had declined. For intensity, the 
strain in caring for ego may have caused the decline in 
relationship intensity. For reciprocity, the decline in 
ego's health may have caused the decrease in ego's ability 
to reciprocate. To answer these questions future research 
will need to either extend its longitudinal time frame 
further backward or incorporate some retrospective ques- 
tioning on these variables. 

While the controls — race and sex — did not explain the 
process of ACLF entry, the socioeconomic status of the 
elderly did have an effect on labeling and referral. If the 
new resident's care was being financed by the state, a 
professional was more likely to be the source of both prob- 
lem labeling and ACLF referral. This is probably due to the 



241 

involvement of social workers in the management of the care 
of those residents under the state program, as the role of 
physicians as well as any other health professionals is 
secondary. 

Tie Duration and Returning Home 

While "strong" network characteristics were demon- 
strated to have an effect on delaying ACLF entry, contrary 
to the findings of Greenley (1972) and Wan and Weissert 
(1981), once entry had occurred, these same network char- 
acteristics were not demonstrated to increase the prob- 
ability of ego returning home. In fact, as outlined in 
Chapter Eleven, those who returned home came from networks 
to which they were less emotionally bonded, and in as low a 
contact with, and as materially linked to as those who 
remained in the ACLF. 

These findings are supportive of the theorized rela- 
tionship between high network bondedness, density, degree, 
and reciprocity and delayed ACLF entry. If the elderly come 
from one of these "stronger" networks, quite a bit of re- 
grouping is likely to be necessary to make it possible for 
them to return home. Alternatively, while "weaker" networks 
may have less regrouping to do, they may be unable to do so. 
The end result would be as observed; positive network char- 
acteristics were not a sufficient force to increase the 
elderly' s probability of returning home. 



242 

The controls — race, health, and socioeconomic status — 
had a significant and relatively greater effect on returning 
home. The effect of health was nearly triple that of any of 
the other variables, indicating that while other contingen- 
cies (in this case being nonwhite, paying for their own 
care, or having a weaker primary network) affected the 
probability of the elderly going home, their health was of 
primary importance in explaining this phase of the institu- 
tionalization process. This extends the research of 
labeling theorists into a domain other than mental illness 
(Goffman, 1961; Greenley, 1972; Scheff, 1966), and renders 
support to the hypothesis that while the process of institu- 
tionalization is affected by social and cultural variables, 
the "objective" health state of an individual is of more 
primary importance (Gove, 1976; Gove and Fain, 1973; Gove 
and Howell, 1974) . 

Unlike with the analysis of returning home, with the 
exception of Time 1 levels of contact, the effect of con- 
trols on tie duration was generally secondary to that of 
network variables. As with the analysis on ego's presenting 
health severity, the effect of density on ego's tie duration 
was primary. While the effect of density varied by focal 
network and type of contact, density was positively related 
to total primary and relative network visiting and speaking, 
closest other visiting and speaking, and total primary and 
relative material linkages at Time 2. The extensiveness of 



243 



these findings coupled with the resultant nonexplanatory 
power of intensity and degree lends significant support to a 
hypothesis that is central both in this study and in network 
theory: It is the density of one's network, i.e., the 
percentage of possible intranetwork connections realized, 
that is most likely to affect the likelihood of a relation- 
ship being maintained or severed (Granovetter, 1973, 1981; 
Hammer, 1963, 1981) . 

The hypothesized relationship between reciprocity and 
tie duration was also confirmed: The greater the degree of 
reciprocity characterizing the elderly' s network relation- 
ships at the time of ACLF entry, the more likely those 
relationships were to endure. These results are supportive 
of the work of Gouldner (1960) , Horowitz and Shindelman 
(1983) , and Wentowski (1981) . According to the theorized 
effect of reciprocity on tie linkages, two primary reasons 
people "do for" others are to return past services and to 
obligate the recipient for future assistance. Thus, these 
findings suggest that when the elderly had been able to 
maintain a relatively high degree of balance in their rela- 
tionships prior to ACLF entry, that network members may not 
yet feel that they have already "repaid" the new resident 
for services rendered in the past and hence expended the 
required effort to continue to "do for" them by remaining in 
contact with them. 



244 



The effect of reciprocity also varied by focal network 
and type of contact. Furthermore, the effect of network 
variables varied by tie duration indicator, with the least 
restrictive indicator better explained. These results, 
coupled with the qualitative data presented in Chapter Ten, 
introduced another new idea to this study: Network vari- 
ables have their greatest effect on tie duration methods of 
least resistance for that network. For relatives, visiting 
contact appeared to have the least barriers; for nonrela- 
tives, writing contact. Additionally, "doing for" the 
elderly by remaining in contact with them after ACLF was 
easier than maintaining material linkages for both relative 
and nonrelative primary network members. 

Finally, while nonrelative network variables had no 
effect on nonrelative contact at Time 2 or material linkage, 
the effect of nonrelative density and nonrelative recipro- 
city on closest other visiting and speaking, coupled with 
the qualitative data presented in Chapter Ten, lends further 
support to the importance of taking into account the inter- 
connections between all of ego's primary network members in 
theory and research on caring for the elderly and institu- 
tionalization of the elderly. 

Practical Imp! icati nn.fi 
If we adapt the stance that we must accommodate to the 
health care needs of our elderly incrementally, as 



245 

advocated by Streib et al. (1984), results from this study 
suggest that ACLFs hold promise of being an exemplary 
within-system change addressed to these demands. However, 
this is not to imply that ACLFs are a near-perfect phenom- 
enon. Direction for improvement also emerged from the 
analysis of data from new residents and key members of their 
networks. 

Strategies to Improve Ut ilization 

A principal goal of any health care service is that it 
be optimally utilized. Both under- and overutilization are 
to be avoided. This necessitates that any given service be 
accessible and available as well as that options compli- 
menting that service be accessible and available. 

In terms of ACLF entry, results suggest that the goal 
of optimal utilization has yet to be reached. Both unneces- 
sary as well as overutilization of the ACLF exists. While 
ACLFs are generally perceived as a "last resort" option, 
networks had low utilization of home support services prior 
to ego's ACLF entry. This fact, coupled with the high 
variability in ego's presenting health status, implies that 
at least for some residents ACLF entry may have been unnec- 
essary or premature. Yet, for other residents ACLFs may 
assume a short-term caring function when ego's network is 
unwilling or unable to provide this service. 



246 

As the network variables density, reciprocity, and 
intensity were demonstrated to be directly related to the 
severity of ego's presenting health, it follows that strate- 
gies oriented to delaying ACLF entry should focus on 
strengthening these characteristics of ego's primary net- 
work. After identifying ego's primary network, intranetwork 
density may be increased by working with ego and network 
members to develop a cohesive plan to meet ego's affective 
and instrumental needs. This would serve to make network 
members aware of each other's roles and help them to work 
together more efficiently and effectively. 

The proportion of reciprocal links can be increased 
both directly and indirectly. Indirectly, an increase can 
be attained by providing more professional home care ser- 
vices, decreasing ego's dependency on network members. If 
an improvement in ego's health is a consequence of these 
services, a direct increase in ego's ability to reciprocate 
may result. As the data indicated that only 15% of the 
residents had been receiving formal support services before 
ACLF entry, much room for improvement in this area exists. 

By increasing intranetwork linkages and decreasing the 
service demands for network members, professionals will 
facilitate network accommodation to ego's needs and delay 
ACLF entry. These actions may also stabilize the emotional 
bondedness ego's network has with ego, as results indicated 
that unlike the relationship with ego's closest other, the 



247 



strain of caring for ego at home tends to lower the over all 
bondedness ego has with network members as a unit. 

In terms of ego's relationship with his/her closest 
other, efforts should be directed at support and enhance- 
ment. Self-help groups organized for these primary care- 
givers might be useful as may the provision of respite care. 
A similar strategy should be used with nonrelative primary 
group members, as the combined characteristics of this sub- 
sector were demonstrated to have the greatest effect on 
ego's presenting health severity. 

Thus, this researcher advocates, as do Biegel, Shore, 
and Gordon (1984) , that because most elderly do have a 
network of concerned others, health professionals should 
also focus on this network when developing strategies for 
assisting the frail elderly to remain in their homes. While 
these strategies will work to prevent unnecessary ACLF 
entry, different variables need modification to assure ac- 
cess to ACLFs when their services are needed. Central among 
these is educating both the public and health professionals 
of the nature of this type of care facility. Although the 
small role of the residents in self-labeling and referral is 
in part accounted for by their degree of infirmity at the 
time of these decisions, their lack of knowledge of ACLFs 
can not be discounted. The low involvement of physicians 
and absolute uninvolvement of nurses in this decision-making 



248 

process is also in need of being corrected, as these profes- 
sionals are primary referral sources for the public. 

In addition to the importance of having knowledge of 
the ACLF option, socioeconomic and attitudinal barriers also 
limit appropriate ACLF utilization. Although socioeconomic 
status and race did not explain ego's presenting health 
severity, going home was explained by ego's race and socio- 
economic status. In terms of cost, while ACLFs unquestion- 
ably present the elderly and/or their network members with 
constant economic demands, the cost of ACLF care is approxi- 
mately one-half that of nursing home care, and depending on 
the extent of ego's care needs may be cheaper than the cost 
of home care. 

While a collection of government programs have made it 
possible for ego and/or network members to reallocate the 
financial responsibility for ego's home care or nursing home 
care to the government, these options are relatively limited 
for the payment of ACLF care. Thus, for many the ACLF 
option is a greater personal expense than nursing home care 
or home care. A need to rethink long-term care policy 
incorporating an ACLF option clearly exists. 

In terms of cultural or attitudinal barriers, while it 
would be foolish to try to attempt to make ACLFs more ap- 
pealing than one's own home, attempts to make them more 
attractive might well center on maximizing their "homelike" 
nature. It then follows that any move towards improvement 



249 



of these structures must minimize accompanying bureaucratic 
elements. 

Strategies to Improve ACLF Caring 

This researcher has demonstrated that two problematic 
consequences of ACLF entry are decreased frequency of con- 
tact with network members and decreased network material 
linkages with ego. As persons in ego's informal network are 
key sources of material and nonmaterial linkages with ego 
(see Chapter Six) , moves to counter this situation are 
indicated. Furthermore, as was demonstrated by Arling, 
Hawkins, and Capitman (1986), and Ryden (1984, 1985), main- 
taining social contacts is also related to one's sense of 
personal control. Working to maintain these contacts may 
act to counter the decrease in personal control and stress 
that is experienced by some of the elderly with ACLF entry. 

As decreased tie contact is explained by the char- 
acteristics of ego's network, and by the structure of ACLFs, 
a dual intervention strategy is suggested. Both a network 
intervention strategy and an effort to decrease contact 
barriers secondary to moving into an ACLF should be 
attempted. However, as a key positive feature of ACLFs is 
their noninstitutionalized character, it is important that 
in implementing both of these strategies one works within 
the ACLF as much as possible, minimizing the potential for 
increasing its bureaucratic flavor. 



250 



The implementation of a network support strategy neces- 
sitates that ACLF managers have a working knowledge of the 
members of ego's primary network. This would be greatly 
facilitated by a structured network assessment at the time 
of ACLF entry. Good examples of these are illustrated in 
Biegel, Shore, and Gordon (1984) . 

As relative visiting contact does not decline during 
the first six months after ACLF entry, maintaining these 
relationships is a useful network support strategy for ACLF 
managers. Along these lines the following tactics might be 
helpful: 

1. The importance of the relatives' continued 
contact with new residents should be stressed. 

2. Relatives should be regularly encouraged to 
attend functions planned for their inclusion. 

3. Relatives should be made to feel "at home" 
during their visits as well as feel that 
their visits were valued by residents and 
staff. 

4. Self-help groups directed for the significant 
others of residents should be organized. 

5. Relatives should be encouraged to volunteer 
(or possibly be compensated indirectly by a 
reduction in the resident's bill) to coordinate 
activities for the residents. 



251 

Given that nonrelative visiting was particularly prone 
to decline, ACLF managers need to make a special effort to 
include these close others in ACLF-orchestrated functions. 
Planning reponsibilities could be dispersed by organizing 
committees of the healthier residents and giving them some 
of this responsibility. Another approach that could be 
helpful for the smaller ACLFs would be for them to combine 
efforts and alternate their planning responsibilities. 

In addition to facilitating visiting contact, telephone 
and written contact remain important avenues of communica- 
tion with network members which need to be maintained. As 
barriers within the ACLF have a great effect on phone com- 
munication with network members after ACLF entry, particular 
attention is needed in this area. Simply alerting the new 
resident and his/her network of the importance of acquiring 
a phone may go along way to decreasing the problem. Having 
centrally located portable phones would be a helpful within- 
system ACLF response. 

While letter writing did not decline at ACLF entry, it 
did not increase either. In addition to requiring the 
availability of stamps and postcards or envelopes, letter 
writing often demands the assistance of staff or network 
members. Its importance should be stressed. Allotting a 
block of time within the week would be a useful way of 
facilitating staff's assistance in this area. 



252 

As primary network density was directly associated with 
contact frequency, the coordination of intranetwork ties 
also remains an important approach. This means that ACLF 
managers need to make an effort both to identify ego's 
primary network and then to determine how network members 
can jointly function to maintain contact with ego. Along 
these lines interviews revealed that contact with nonrela- 
tive network members was often dependent on the efforts of 
relatives to transport these key others to the ACLF. Addi- 
tionally, network members need to know that the support they 
provide to each other has a significant enhancing effect on 
their relationships with ego. 

A positive relationship between tie reciprocity and tie 
continuity was also demonstrated. As noted earlier, reci- 
procity can be increased both by decreasing the number of 
unreciprocated services network members need to provide for 
ego and by increasing ego's ability to reciprocate to net- 
work members for services provided. The act of ACLF entry 
is normally associated with a decrease in network responsi- 
bilities for ego, which could work to provide a more even 
give and take in network relationships. Yet, a balance 
must be sought in the need for ACLFs to provide relief for 
ego's network in caring for ego and in continuing to en- 
courage network members to be involved in doing for ego and, 
thus, to maintain some material linkages with ego. 

Additionally, while the increase in ego's dependent 



253 



status is unavoidable with ACLF entry, efforts should be 
directed at allowing ego to continue to do for others. To 
this end, staff assistance with letter writing, gift pur- 
chases, or outgoing telephone calls would be helpful. For 
instance, residents may be able to provide supportive tele- 
phone calls to friends struggling to remain at home, which 
would maintain ties, build resident self-esteem, and help 
delay institutionalization for an at-risk group of elderly. 

In conclusion, as the long-term care needs of our 
rapidly aging population place increasingly heavy demands on 
our nation's already strained health budget, continual anal- 
ysis of our response to the health needs of the elderly is 
prudent. Along these lines, alternatives that reduce the 
cost of care without sacrificing its effectiveness must be 
explored. Adult Congregate Living Facilities are one such 
alternative. This researcher contributes to this need by 
examining the process by which the elderly are relocated in 
ACLFs. It should provide both health providers and re- 
searchers with more information regarding the relationship 
between social networks and health care utilization. More- 
over, it contributes necessary descriptive information about 
the nature of the ACLF population and their networks. Thus, 
this study provides information useful toward the effective 
and efficient expenditure of our health dollar, as well as 
contributing to the knowledge base of network analysis. 



APPENDIX A 
EMOTIONAL BONDEDNESS- SCALE 



EMOTIONAL BONDEDNESS SCALE 

1. I can count on this person to stand by me. 

2. Sometimes makes me angry or upset.** 

3. Is sensitive to my feelings and moods. 

4. Listens to my problems and worries. 

5. Sometimes hurts my feelings.** 

6. Thinks highly of what I know and can do. 

7. Sometimes makes me discouraged.** 

8. Often cheers me up. 

9. We see eye to eye on most things. 

10. We often have trouble getting along together.** 

11. We really enjoy spending time together. 

12. We get along better with each other when we keep our 
feelings to ourselves.** 

**Reverse coded items 



To each of these items the individual responds with one 
of the following: Not at all true of him/her, somewhat true 
of him/her, or very true of him/her. Scores range from 1 to 
3 for each item, with 3 denoting high emotional bondedness 
(Snow and Crapo, 1982). 



255 



APPENDIX B 
SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE 



SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE 
1. What is the date today?. 



Month Day Year 
2. What day of the week is it? 



3. What is the name of this place?. 

4. In which room do you live? 

5. How old are you? 



6 . When were you born?. 



7. Who is the president of the U.S. now?. 

8. Who was president just before him? 



9. What was your mother's maiden name?. 



10. Subtract 3 from 20 and keep subtracting 3 from each 
new number all the way down. 



Total number of errors 



To be completed by interviewer: 
Resident's name: Date 



Sex: 1. Male Race: 1. White 

2. Female 2. Black 

3. Other 

Years of education: 1. Grade school 

2. High school 

3 . Beyond high school 



Up_t£: This tool is adapted for an Adult Congregate Living 
population from Pfeiffer's 1975 questionnaire. 



257 



APPENDIX C 
INDEX OF INDEPENDENCE 
IN ACTIVITIES OF DAILY LIVING 



INDEX OF INDEPENDENCE 
IN ACTIVITIES OF DAILY LIVING 



The index of independence in Activities of Daily Living 
is based on an evaluation of the functional independence or 
dependence of patients in bathing, dressing, going to 
toilet, transferring, continence, and feeding. Specific 
definitions of functional independence and dependence appear 
below the index. 

A. Independent in feeding, continence, transferring, 
going to toilet, dressing, and bathing 

B. Independent in all but one of these functions 

C. Independent in all but bathing and one additional 
function 

D. Independent in all but bathing, dressing and one 
additional function 

E. Independent in all but bathing, dressing, going to 
toilet, and one additional function 

F. Independent in all but bathing, dressing, going to 
toilet, transferring and one additional function 

G. Dependent in all six functions 

Other. Dependent in at least two functions, but not 
classifiable as C, D, E, or F 

Independence means without supervision, direction or active 
personal assistance, except as specifically stated below. 
This is based on actual status and not on ability. A 
patient who refuses to perform a function is considered as 
not performing the function, even though he/she is deemed 
able. 

For each of following functions, circle that which applies 
to ego. Questions are to be addressed to ego's current 
primary caretaker. 



259 



260 



Bathing (sponger shower r or tubl 

Independent: Assistance only in bathing a single part (as 
in back or disabled extremity) or bathes self completely 

Dependent: Assistance in bathing more than one part of 
body; assistance in getting in or out of tub, or does not 
bath self 



Dressing 

Independent: Gets clothes from closets and drawers; puts 
on clothes, outer garments, braces; manages fasteners; 
act of tying shoes is excluded 

Dependent: Does not dress self or remains partly undressed 



Going to Toilet 

Independent: Gets to toilet; arranges clothes, cleans 
organs of excretion (may manage own bedpan used at night 
only and may or may not be using mechanical supports) 

Dependent: Uses bedpan or commode or receives assistance 
in getting to and using toilet 



Transfer 

Independent: Moves in and out of bed independently and 
moves in and out of chair independently (may or may not 
be using mechanical supports) 

Dependent: Assistance in moving in or out of bed and/or 
chair; does not perform one or more transfers 



Continence 

Independent: Urination and defecation entirely self- 
controlled 

Dependent: Partial or total incontinence in urination or 
defecation; partial or total control by enemas, catheters, 
or regulated use of urinals and/or bedpans 



261 



Feeding 

Independent: Gets food from plate or its equivalent into 
mouth (precutting of meat and preparation of food as 
buttering bread are excluded from evaluation) 

Dependent: Assistance in act of feeding (see above) ; does 
not eat at all or parenteral feeding 



Note : Taken from Katz (1963:915) 



APPENDIX D 

INITIAL QUESTIONNAIRE 
ADDRESSED TO RESIDENT 



INITIAL QUESTIONNAIRE 
ADDRESSED TO RESIDENT 



My name is Mary Bear. I am doing research for a 
University of Florida study on the lifestyles of older 
persons. More specifically, the study focuses on the 
process by which older people decide to live in Adult 
Congregate Living Facilities (ACLFs) and the effects of 
these decisions on their family and friendship 
relationships. 

The purpose of this questionnaire is to obtain 
information about how you decided to move to an ACLF and 
how that move has affected your family and friendship 
relationships. It will take about one hour. There are no 
right or wrong answers. All of your answers are 
confidential. They will not be shared with your family, the 
staff at the ACLF, or anyone else. Will you please give me 
permission to ask you these questions? 

Informed consent obtained not obtained 

(Only proceed if informed consent is obtained.) 

1. First, I need to ask you some basic questions to check 
your memory. Proceed with the modified Pfieffer scale 
(see Appendix B) . A score of mild impairment or above 
must be obtained to proceed with the questionnaire. 

2. I would like to begin with some questions regarding 
your move into an ACLF. Could you briefly explain 
what your living situation was like before you moved 
here? (Were you living alone? With a family member? 
Were you having any problems getting along? If so, 
what were they?) 

3. Who first suggested that you might have to move into 
another living situation? 

A relative 

A personal contact 

Your doctor, or another health professional 

(i.e., nurse or a social worker) 
You determined it yourself 



263 



264 



In general, how were you feeling at that time? 

Very good 

Good 

Fair 

Poor 



Who first suggested that moving into an ACLF might be a 
good idea? 

A relative 

A personal contact 

Your doctor or another health professional 

(i.e., a nurse or a social worker) 
You determined it yourself 



6. Could you briefly explain how you felt about moving to 
an ACLF? (Was it a last alternative? Preferred over 
going to a nursing home? Resisted at all costs? The 
best available option?) 

7. Did any of your relatives or personal contacts 
discourage you from moving to an ACLF? 

Yes 

No 



8. Once you decided to move to an ACLF, was your move 
delayed due to 

Lack of space in the ACLF of your choice 

Financial problems 

Difficulties in selling your home or other 

possessions 

Other 

No delays were experienced 



9. Which of the following describes how you pay for your 
care at this ACLF? 

I pay for my care myself 

My family pays for my care 

The state of Florida pays for my care 

Other 



10. Now I would like you to identify two groups of people. 
In the first group, will you please include all of the 
relatives that you have been in contact with on a 
fairly regular basis in the past year. (By a contact, 
I mean either a phone call, a letter, or a visit). 



265 



The second group is to include all of the adults you 
feel close to (excluding relatives and other residents 
at this ACLF) and have been in contact with on a fairly 
regular basis during this past year. [List network in 
charts at the end of the questionnaire. Record answers 
to (10)-(12) in same charts.] 

Now for each person you identified, I am going to 
ask you a series of general questions about your 
relationship. 

10a. What is the person's name? 

10b. What is the basis of your relationship? (sibling, child, 
spouse, friend etc.) 

10c. About how long have you been acquainted with ( )? 
Note: Score (Id), (le), and (If) in terms of times 
per week, times per year, or times per month. 

lOd. On average, about how often have you seen ( ) during 
this past year? 

lOe. About how often have you talked with ( ) during this 
past year? 

lOf. About how often have you exchanged letters with ( ) 
during this past year? 

lOg. Does ( ) give you any financial assistance? 

lOh. Does ( ) give you personal assistance (i.e., rides to 
the doctor, take you shopping, do your laundry) when 
you need it? 

lOi. Do you receive gifts from ( )? 

10 j. Do you provide ( ) with any financial assistance? 

10k. Do you provide ( ) with any other personal assistance 
now, or have you in the past? 

101. Do you give ( ) gifts? 

11. Now, for each person you identified I am going to ask 
you some questions concerning how you feel about that 
person. Please respond with one of the following: 
Not at all true of him/her (NT) , somewhat true of 
him/her (ST) , or very true of him/her (VT) . 



266 

11a. I can count on this person to stand by me. 

lib. Sometimes makes me angry or upset. 

lie. Is sensitive to my feelings and moods. 

lid. Listens to my problems and worries. 

lie. Sometimes hurts my feelings. 

llf. Thinks highly of what I know and can do. 

llg. Sometimes makes me discouraged. 

llh. Often cheers me up. 

Hi. We see eye to eye on most things. 

11 j. We often have trouble getting along together. 

Ilk. We really enjoy spending time together. 

111. We get along better with each other when we keep our 
feelings to ourselves. 

12. When you consider everything that you share with ( ), 
i.e., personal assistance, gifts, financial assistance, 
and love and companionship, would you consider that 
over the long run you get about as much from ( ) as 
you give to ( ) ? 

13. Who would you consider to be the person closest to you 
who lives in the Orlando area? 

14. Would you mind if I contacted your closest contact and 
asked him/her some similar questions? 

Yes 

No 



15. What is his/her address and phone number? 

16. How old are you? 

60-64 

65-69 

70-74 

75-79 

80 + 



267 



17. List each of ego's network members in a random pattern 
on a blank sheet of paper. Assist the respondent in 
connecting each of these members who are currently in 
fairly regular contact with each other. Identify the 
relationship to ego as relative (R) or nonrelative (NR) 
A sample response is illustrated below. 



r— E 9° 



Helen— (NR 
Landon — (R 



Arla--(R) 
Erma — (R) 




Trudi— (NR) - 

Lorraine — (R) 

Jack— (R) — 

Marvin — (R) — 

Sue— (R) 



all connected 
to each other 



Total N = 10 
Total Na = 36 
Total Density = 80% 
Total Degree =7.2 



Relative N = 8 
Relative Na = 26 
Relative Density = 92.9% 
Relative Degree = 6.5% 



Nonrelative N = 3 
Nonrelative Na = 2 
Nonrelative Density = 66.7% 
Nonrelative Degree =1.3 



268 



NETWORK CHART 



10a. Name 



10b. Tie basis 



10c. How long known * 



lOd. Seen 



lOe. Spoken with 



lOf. 


Letters 




* 


* 


* 


* 


lOg. 


Receives 


money 


* 


* 


* 


* 


lOh. 


Receives 


help 


* 


* 


* 


* 


lOi. 


Receives 


gifts 


* 


* 


* 


* 


lOj. 


Provides 


money 


* 


* 


* 


* 


10k. 


Provides 


help 


* 


* 


* 


* 


101. 


Provides 


gifts 


* 


* 


* 


* 


11a. 


Counts on 


* 


* 


* 


* 


lib. 


Angry 




* 


* 


* 


* 


lie. 


Sensitive 


i 


* 


* 


* 


* 


lid. 


Listens 




* 


* 


* 


* 


lie. 


Hurts feelings 


* 


* 


* 


* 


llf. 


Thinks highly 


* 


* 


* 


* 


llg. 


Discourages 


* 


* 


* 


* 


llh. 


Cheers up 


> 


* 


* 


* 


* 


Hi. 


Eye to eye 


* 


* 


* 


* 


llj. 


Trouble 




* 


* 


* 


* 


Ilk. 


Enjoys time 


* 


* 


* 


* 



111. Keeps feelings * 



269 



12. Feels balanced * 



APPENDIX E 
INITIAL QUESTIONNAIRE 
ADDRESSED TO RESIDENT'S CLOSEST OTHER 



INITIAL QUESTIONNAIRE 
ADDRESSED TO RESIDENT'S CLOSEST OTHER 



My name is Mary Bear. I am doing research for a 
University of Florida study on the life styles of older 
persons. More specif ically, the study focuses on the 
process by which older people decide to live in Adult 
Congregate Living Facilities (ACLFs) and the effects of 
these decisions on their family and friendship 
relationships. 

I obtained your name and the information necessary to 
contact you from ( ) . The purpose of this questionnaire is 
to obtain information on how it was decided that ego 
(substitute name of resident for ego throughout the 
questionnaire) would move into an ACLF and how that move has 
affected ego's family and friendship relationships. It 
will take about one hour. There are no right or wrong 
answers. All of your answers are confidential. They will 
not be shared with ego or anyone else. Would you please 
give me permission to ask you some questions? 

Informed consent obtained not obtained 

(Only proceed if informed consent is obtained.) 

1. I would like to begin with some questions regarding 
ego's move into an ACLF. Could you briefly explain 
what ego's living situation was like at that time? 
(Was ego living alone? With a family member? Was 
ego having any problems getting along? If so, what 
were they?) 

2. Who first suggested that ego might have to move into 
another living situation? 

A relative of ego 

A personal contact of ego 

Ego's doctor, or another health professional 

(i.e., a nurse or a social worker) 
Ego determined it him-/herself 



271 



272 



3. In general, how was ego feeling at that time? 

Very good 

Good 

Fair 

Poor 



4. Who first suggested that moving into an ACLF might 
be a good idea for ego? 

A relative of ego 

A personal contact of ego's 

Ego's doctor or another health professional 

(i.e., a nurse or a social worker) 
Ego determined it him-/herself 



5. Could you briefly explain how ego felt about moving 
to an ACLF? (Was it a last alternative? Preferred 
over going to a nursing home? Resisted at all 
costs? The best available option?) 

6 . Did any of ego's relatives or personal contacts 
discourage him/her from moving to an ACLF? 

Yes 

No 



Once the decision was made to move ego to an ACLF, 
was the move delayed due to 

Lack of space in the ACLF of your choice 

Financial problems 

Difficulties in selling ego's home or other 

possessions 

Other 

No delays were experienced 



Which of the following best describe how ego pays for 
his/her care at this ACLF? 

Care is paid by ego 

Family pays for care 

State of Florida pays for care 



Other 



I would like you to identify two groups of people. In 
the first group, will you please include all of the 
relatives that ego has been in contact with on a 
fairly regular basis in the past year. (By a contact, 
I mean either a phone call, a letter, or a visit.) 



273 



The second group is to include all of the adults ego 
feels close to (excluding relatives and other 
residents at the ACLF where ego currently lives) and 
has been contact with on a fairly regular basis 
during this past year. [List network in charts at 
the end of the questionnaire. Record answers to (9)- 
(12) in same charts. Include yourself in the 
appropriate category] . Now, for each person you 
identified, I am going to ask you a series of general 
questions about their relationship with ego. 

9a. What is the person's name? 

9b. What is the basis of the relationship? (sibling, 
spouse, child, friend, etc.) 

9c. About how long has ego been acquainted with ( )? 
Note: Score (Id), (le) , and (If) in terms of times 
per week, times per month or times per year. 

9d. On average, about how often has ego seen ( ) during 
the past year? 

9e. On average, about how often has ego talked with ( ) 
during the past year? 

9f. On average, about how often has ego exchanged letters 
with ( ) during the past year? 

9g. Does ( ) give ego any financial assistance? 

9h. Does ( ) give ego personal assistance (i.e., rides 
to the doctor, take on shopping trips, help with 
laundry) when ego needs it? 

9i. Does ego receive gifts from ( )? 

9j. Does ego provide ( ) with any financial assistance? 

9k. Does ego provide ( ) with any other personal assistance 
now, or have they in the past? 

91. Does ego give ( ) gifts? 

10. Now, for each person you identified (including 
yourself) , I am going to ask you some questions 
concerning how ego feels about that person. If 
ego's feelings are unknown at this time answer in 
terms of how ego felt the last time he/she was able 
to communicate feelings to you. Please respond 



274 



with one of the following: Not at all true of 
him/her (NT) , somewhat true of him/her (ST) , or 
very true of him/her (VT) . 

10a. Ego can count on this person to stand by him/her. 

10b. Sometimes makes ego angry or upset. 

10c. Is sensitive to ego's feelings and worries. 

lOd. Listens to ego's problems problems and worries. 

lOe. Sometimes hurts ego's feelings. 

lOf. Thinks highly of what ego knows and can do. 

lOg. Sometimes makes ego discouraged. 

lOh. Often cheers ego up. 

10 i. Ego and ( ) see eye to eye on most things. 

10 j. Ego and ( ) often have trouble getting along together. 

10k. Ego and ( ) get along better with each other when they 
keep their feelings to themselves. 

11. When you consider everything that ego shares with ( ), 
i.e., personal assistance, gifts, financial 
assistance, and love and companionship, would you 
consider that over the long run ego gets about as 
much from ( ) as ( ) gets from ego? 

12. Now I am going to ask you the same series of questions 
concerning how you feel about ego. (Add phrase in 
parentheses if ego's mental status has been 
moderately or severely impaired.) 

12a. I could count on this person to stand by me (if 
he/she were able) . 

12b. Sometimes makes me angry or upset. 

12c. Is sensitive to my feelings and moods (as best as 
he/she can be) . 

12d. Listens to my problems and worries (as best as he/she 
can) . 

12e. Sometimes hurts my feelings. 



27 5 

12f. Thinks highly of what I know and can do. 

12g. Sometimes makes me discouraged. 

12h. Often cheers me up. 

12i. We see eye to eye on most things (or used to when ego 
was feeling better) . 

12 j. We often have trouble getting along together. 

12k. We really enjoy spending time together. 

121. We get along better with each other when we keep our 
feelings to ourselves. 

13. How old is ego? 



60- 


-64 


65- 


-69 


70- 


-74 


75- 


-7 9 


80 + 



14. List each of ego's network members in a random pattern 
on a blank sheet of paper. Assist the respondent in 
connecting each of these members who are currently in 
fairly regular contact with each other. Identify the 
relationship with ego as relative (R) or nonrelative 
close other (NR) . 



276 



NETWORK CHART 



9a. 


Name 




* 


* 


* 


* 


9b. 


Tie basis 


* 


* 


* 


* 


9c. 


How long 


known 


* 


* 


* 


* 


9d. 


Seen 




* 


* 


* 


* 


9e. 


Spoken with 


* 


* 


* 


* 


9f. 


Letters 




* 


* 


* 


* 


9g. 


Receives 


money 


* 


* 


* 


* 


9h. 


Receives 


help 


* 


* 


* 


* 


9i. 


Receives 


gifts 


* 


* 


* 


* 


9j. 


Provides 


money 


* 


* 


* 


* 


9k. 


Provides 


help 


* 


* 


* 


* 


91. 


Provides 


gifts 


* 


* 


* 


* 


10a. 


Counts on 


* 


* 


* 


* 


10b. 


Angry 




* 


* 


* 


* 


10. 


Sensitive 


i 


* 


* 


* 


* 


lOd. 


Listens 




* 


* 


* 


* 


lOe. 


Hurts feelings 


* 


* 


* 


* 


lOf. 


Thinks highly 


* 


* 


* 


* 



lOg. Discourages 



lOh. Cheers up 



10 i. Eye to eye 



10 j. Trouble 



10k. Enjoys time 



277 



101. Keeps feelings 



11. Feels balanced 



APPENDIX F 
FOLLOW-UP QUESTIONNAIRE 
ADDRESSED TO RESIDENT 



FOLLOW-UP QUESTIONNAIRE 
ADDRESSED TO RESIDENT 



Hello, my name is Mary Bear. I visited with you 
approximately six months ago in regards to my study for the 
University of Florida on the process by which an older 
person comes to move into an ACLF. I am finishing up my 
study now and have stopped by to see how you are doing at 
this time. The questions I would like to ask you will take 
about forty-five minutes. As before, there are no right or 
wrong answers and all of your answers are confidential. 
They will not be shared with your family, the staff at this 
ACLF, or anyone else. Would you please give me permission 
to ask you these questions? 

Informed consent obtained not obtained 

Date of follow-up interview 

To be completed by interviewer after talking with 
caregiver of ego's original residence. 

Resident's name 

Current address 



If ego has died, prior to his/her death, did ego 

(0) Remain at the original ACLF 

(1) Return to his/her home 

(2) Go to the home of a friend/relative 

(3) Go to a nursing home 

(4) Go to a hospital 

(5) Other 

Score from Katz Activities of Daily Living 
Questionnaire (see Appendix D) 

First, I need to recheck your memory. Proceed with the 
moif ied Pfeif fer scale (see Appendix B) . 

If a score of mild impairment or above is obtained and 
ego has moved, go to (2) . 

If a score of mild impairment or above is obtained and 
ego is at the same residence, go to (9). 



279 



280 



If a score of moderate or severe impairment is 
obtained, end the interview with ego and contact 
alter as per Appendix G. 

2. I received your address from (insert source). How are 
things going for you now? 



3. Which of the following describe the reasons for your 
move? (You can circle more than one.) 

(0) My health improved 

(1) My health worsened 

(2) I was not happy with where I was 

(3) My friends/relatives were not happy with 
where I was 

(4) I could no longer afford the fee 

(5) Other 

4. How would you describe the physical care you received 
at (insert name of original ACLF) ? 

(0) The caregivers gave me excellent physical 
care 

(1) The caregivers gave me adequate physical 
care 

(2) The caregivers gave me less than adequate 
physical care 

5. How would you describe the emotional atmosphere at 
(insert name of original ACLF)? 

(0) The caregivers seemed really to care about 
me 

(1) The caregivers were pleasant, but did not 
seem really to care about me 

(2) The caregivers were not pleasant and did 
not seem really to care about me 



281 



6. Which of the following best compares your current 
physical care with that received at (insert name 
of former ACLF)? 

(0) The caregivers here give me a higher level 
of technical care 

(1) The caregivers here give me the same level 
of technical care 

(2) The caregivers here give me a lower level 
of technical care 

7. Which of the following best compares the emotional 
atmosphere in your current residence with that 
experienced at (insert name of former ACLF)? 

(0) The caregivers here seems to care more 
about me 

(1) The caregivers here seem to care the same 
about me 

(2) The caregivers here seem to care less 
about me 

8. Could you please identify any problems that you or 
your caregivers are currently experiencing? [Go on 
to (12) .] 

9. How are things going for you now? 

10. How would you describe the physical care you have been 
receiving? 

(0) The caregivers here give me excellent 
physical care 

(1) The caregivers here give me adequate 
physical care 

(2) The caregivers here give me less than 
adequate physical care 

11. How would you describe the emotional atmosphere here? 

(0) The caregivers here seem really to care 
about me 

(1) The caregivers here are pleasant, but don't 
seem really to care about me 

(2) The caregivers here are not pleasant and 
do not seem really to care about me 



(0) 

(1) 


(2) 


(3) 


(4) 
(5) 


(6) 
(7) 


(8) 


(9) 
(10) 



282 



12. Which of the following best describes your current 
living condition? 

I am living alone without any help 

I am living alone with the help of my 

family and friends 

I am living alone with the help of formal 

agencies 

I am living alone with the help of family 

and friends and formal agencies 

I am living with family/friends 

I am living with family and friends and 

being helped by formal agencies 

I am in a nursing home 

I am in a hospital, but plan to return 

to an ACLF 

I am in a hospital and don't plan to return 

to an ACLF 

I am in the same ACLF 

I am in a new ACLF 

13. Which of the following best describes your current 
"fit" with your living situation? 

(0) Very good 

(1) Good 

(2) Fair 

(3) Poor 

14. At this time how would you describe your overall 
health? 

15. Since I first saw you, would you say that your overall 
health has 

(0) Improved greatly 

(1) Improved slightly 

(2) Stayed the same 

(3) Declined slightly 

(4) Declined greatly 

16. Since I first spoke with you, would you say that your 
lifestyle has 

(0) Improved greatly 

(1) Improved slightly 

(2) Stayed the same 

(3) Declined slightly 

(4) Declined greatly 



283 



17. Now I want to move on to some questions about your 
family and friends. The last time we visited, you 
identified two groups of adults with whom you had been 
in contact with on a fairly regular basis the year 
before you moved into the ACLF. The first group 
consisted of relatives, and second was all the adults 
you felt close to (excluding relatives and other 
residents at this ACLF) . 

I have those names with me. Now for each person you 
identified, I am going to ask you a series of 
general questions about your relationship with them 
over the past six months. [List network in charts 
in back of questionnaire. Record answers to (17) 
in the same chart.] 

17a. Name to be inserted by interviewer. 

17b. Relationship to be inserted by interviewer. 

17c. In the past six months, how often have you seen ( )? 

(1) Not at all 

(2) Once 

(3) Every other month 

(4) Every month 

(5) Every other week 

(6) Once a week 

(7) Several times a week 

(8) Daily 

17d. On average, in the past six months, about how often 
have you talked with ( )? (Code as above.) 

17e. On average, in the past six months, about how often 
have you exchanged letters with ( )? (Code as 
above.) 

17f. On average, in the past six months, has ( ) give you 
any financial assistance? 

(0) No 

(1) Yes 

17g. In the past six months, has ( ) given you any personal 
assistance? 

(0) No 

(1) Yes 



284 



17h. In the past six months, has ( ) given you any gifts? 

(0) No 

(1) Yes 

17i. In the past six months, have you provided ( ) with 
any financial assistance? 

17 j. In the past six months, have you provided ( ) with 
any personal assistance? 

(0) No 

(1) Yes 

17k. In the past six months, have you given ( ) any gifts? 

(0) No 

(1) Yes 



285 



NETWORK CHART 



17a. 


Name 




* 


* 


* 


* 


17b. 


Tie basis 


* 


* 


* 


* 


17c. 


Seen 




* 


* 


* 


* 


17d. 


Spoken with 


* 


* 


* 


* 


17e. 


Letters 




* 


* 


* 


* 


17f. 


Receives 


money 


* 


* 


* 


* 


17g. 


Receives 


help 


* 


* 


* 


* 


17h. 


Receives 


gifts 


* 


* 


* 


* 


17i. 


Provides 


money 


* 


* 


* 


* 


17j. 


Provides 


help 


* 


* 


* 


* 


17k. 


Provides 


gifts 


* 


* 


* 


* 



APPENDIX G 
FOLLOW-UP QUESTIONNAIRE 
ADDRESSED TO RESIDENT'S CLOSEST OTHER 



FOLLOW-UP QUESTIONNAIRE 
ADDRESSED TO RESIDENT'S CLOSEST OTHER 



Hello, my name is Mary Bear. I visited you 
approximately six months ago in regards to my study for the 
University of Florida on the process by which an older 
person comes to move into an ACLF. Now I am finishing up 
my study and am calling to ask you some questions about how 
ego* (substitute name of resident for ego throughout the 
questionnaire) is doing at this time. I am also interested 
in learning about how ego's move into the ACLF has affected 
his/her family and friendship relationships. My questions 
will take approximately one-half hour, and, as before, all 
answers will be confidential. 

1. Is this a good time to ask you some questions? 

Yes No [If no, arrange a time to call 

back. If yes, obtain permission to proceed with 
questionnaire. Go to (9) if ego has not moved; 
otherwise, start at (2).] 

Informed consent obtained not obtained 

Date of follow-up interview 

Resident's name 

Score from Katz Activities of Daily Living 

Questionnaire 

(obtained from caregiver at ACLF) 

Score from Short Portable Mental Status Questionnaire 
(obtained after questioning ego) 



♦Complete after researcher has done a mental and physical 
assessment on ego and ego has been deemed incompetent. If 
ego is no longer at the original ACLF and caregiver was 
unable to provide information on ego's current residence, 
begin with Special Section. 



287 






288 



Special Section 

Hello, my name is Mary Bear. I visited you 
approximately six months ago in regards to my study for the 
University of Florida on the process by which an older 
person comes to move into an ACLF. Now I am finishing up my 
study and would like to stop by and see how ego is doing. 
However, I was not able to find ego at (insert name of 
original ACLF) . Could you please tell me where ego is 
currently living? 

Current address 



If ego has died, prior to his/her death, did ego 

(0) Remain at the original ACLF 

(1) Return to his/her home 

(2) Go to the home of a friend/relative 

(3) Go to a nursing home 

(4) Go to a hospital 

(5) Other 

Arrange for a time to call ego's significant other back if 
necessary after visiting with ego. 

Call back time 



(When significant other is called back, return to 
informed consent section of questionnaire on first page.) 



289 



2. How are things going for ego right now? 

3. Which of the following describe the reasons for ego's 
move? (You can circle more than one.) 

(0) Ego's health improved 

(1) Ego's health worsened 

(2) Ego was not happy with where he/she was 

(3) Ego's friends/relatives were not happy with 
where he/she was 

(4) Ego/we could no longer afford the fee 

(5) Other 

4. How would you describe the physical care ego received 
at (insert name of original ACLF) ? 

(0) The caregivers gave ego excellent physical 
care 

(1) The caregivers gave ego adequate physical 
care 

(2) The caregivers gave ego less than adequate 
physical care 

5. How would you describe the emotional atmosphere at 
(insert name of original ACLF)? 

(0) The caregivers seemed really to care about 
ego 

(1) The caregivers were pleasant, but did not 
seem really to care about ego 

(2) The caregivers were not pleasant and did 
not seem really to care about ego 

6. Which of the following best compares ego's current 
physical care with that received at (insert name of 
former ACLF)? 

(0) The caregivers here give ego a higher level 
of technical care 

(1) The caregivers here give ego the same level 
of technical care 

(2) The caregivers here give ego a lower level 
of technical care 



290 



7. Which of the following best compares the emotional 
atmosphere in ego's current residence with that 
experienced at (insert name of former ACLF)? 

(0) The caregivers here seem to care more about 
ego 

(1) The caregivers here seem to care about the 
same for ego 

(2) The caregivers here seem to care less about 
ego 

8. Could you please identify any problems that you or 
ego are currently experiencing? [Go to (12).] 

9. How are things going for ego now? 

10. How would you describe the physical care ego has been 
receiving? 

(0) The caregivers here give ego excellent 
physical care 

(1) The caregivers here give ego adequate 
physical care 

(2) The caregivers here give ego less than 
adequate physical care 

11. How would you describe the emotional atmosphere at the 
ACLF? 

(0) The caregivers here seem really to care 
about ego 

(1) The caregivers here are pleasant, but don't 
seem really to care about ego 

(2) The caregivers here are not pleasant and 
do not seem really to care about ego 

12. Which of the following best describes ego's current 
living condition? 

(0) Ego is living alone without any help 

(1) Ego is living alone with the help of 
family/friends 

(2) Ego is living alone with the help of 
formal agencies 

(3) Ego is living alone with the help of family 
and friends and formal agencies 

(4) Ego is living with family/friends 

(5) Ego is living with family and friends and 
being helped by formal agencies 



291 



13 



(6) Ego is in a nursing home 

(7) Ego is in a hospital , but plans to return to 
the ACLF 

(8) Ego is in a hospital and does not plan to 
return to an ACLF 

(9) Ego is in same ACLF 
(10) Ego is in new ACLF 

Which of the following best describes ego's current 
"fit" with his/her living situation? 



(0) 

(1) 
(2) 
(3) 



Very good 
Good 
Fair 
Poor 



14 



At this time, how would you describe ego's overall 
health? 



(0) Very good 

(1) Good 

(2) Fair 

(3) Poor 

15. Since I first saw you, would you say that ego's overall 
health has 



(0) Improved greatly 

(1) Improved slightly 

(2) Stayed the same 

(3) Declined slightly 

(4) Declined greatly 

16. Since I first spoke with you, would you say that ego's 
lifestyle has 

(0) Improved greatly 

(1) Improved slightly 

(2) Stayed the same 

(3) Declined slightly 

(4) Declined greatly 

17. Since I first spoke with you, would you say that your 
overall lifestyle has 

(0) Improved greatly 

(1) Improved slightly 

(2) Stayed the same 

(3) Declined slightly 

(4) Declined greatly 



292 



18. Now I want to move on to some questions about ego's 

family and friends. The last time we visited, you 

identified two groups of adults that ego had been in 

contact with on a fairly regular basis the year before 
ego moved into the ACLF. The first group consisted of 

relatives and the second was all the adults ego felt 
close to (excluding relatives and other residents 
at the ACLF) . 

I have those names in front of me. Now, for each 
person you identified, I am going to ask you a series 
of general questions about ego's relationship with 
him/her over the past six months. [List network in 
charts in back of questionnaire. Record answers to 
(18) in same chart.] 

18a. Name to be inserted by interviewer. 

18b. Relationship to be inserted by interviewer. 

18c. On average, in the past six months, how often has ego 
seen ( ) ? 

(1) Not at all 

(2) Once 

(3) Every other month 

(4) Every month 

(5) Every other week 

(6) Once a week 

(7) Several times a week 

(8) Daily 

18d. On average, in the past six months, about how often 
has ego talked with ( )? (Code as above.) 

18e. On average, in the past six months, about how often 
has ego exchanged letters with ( )? (Code as above.) 

18f. In the past six months, has ( ) given ego any 
financial assistance? 



(0) 
(1) 



NO 

Yes 



18g. In the past six months, has ( ) given ego any 
personal assistance? 



(0) 
(1) 



NO 
Yes 






293 



18h. In the past six months, has ( ) given ego any gifts? 

(0) No 

(1) Yes 

18i. In the past six months, has ego provided ( ) with any 
financial assistance? 

(0) No 

(1) Yes 

18 j. In the past six months, has ego provided ( ) with any 
personal assistance? 

(0) No 

(1) Yes 

18k. In the past six months, has ego given ( ) any gifts? 

(0) No 

(1) Yes 






294 



NETWORK CHART 



18a. 


Name 




* 


* 


* 


* 


18b. 


Tie basis 


* 


* 


* 


* 


18c. 


Seen 




* 


* 


* 


* 


18d. 


Spoken with 


* 


* 


* 


* 


18e. 


Letters 




* 


* 


* 


* 


18f. 


Receives 


money 


* 


* 


* 


* 


18g. 


Receives 


help 


* 


* 


* 


* 


18h. 


Receives 


gifts 


* 


* 


* 


* 


18i. 


Provides 


money 


* 


* 


* 


* 


18j. 


Provides 


help 


* 


* 


* 


* 


18k. 


Provides 


gifts 


* 


* 


* 


* 



APPENDIX H 

MEANS AND STANDARD DEVIATIONS OF THE CHARACTERISTICS 

OF NEW RESIDENT'S NETWORKS 



Means and standard deviations of the characteristics of new 
residents 1 networks 



Network Characteristics Mean SD N 



Range 



Total personal network 
Relative network 
Nonrelative network 



Density 



Total personal network 
Relative network 
Nonrelative network 

Degree 

Total personal network 
Relative network 
Nonrelative network 

Number of material linkages 

Total personal network 
Relative network 
Nonrelative network 

Range with material linkages 

Total personal network 
Relative network 
Nonrelative network 

Number of dependent linkages 

Total personal network 
Relative network 
Nonrelative network 

Number of reciprocated linkages 

Total personal network 
Relative network 
Nonrelative network 



7.36 


4.11 


81 


4.60 


2.94 


81 


2.83 


2.85 


81 



65.82 


22.54 


77 


88.97 


15.36 


74 


75.10 


25.30 


46 



5.05 


2.61 


77 


4.59 


2.64 


74 


3.68 


2.20 


46 



9.65 


6.20 


81 


7.22 


5.17 


81 


2.46 


3.75 


81 



5.59 


3.38 


81 


3.90 


2.62 


81 


1.83 


2.50 


81 



3.37 


3.74 


81 


2.40 


7.79 


81 


1.01 


2.11 


81 



5.21 


4.83 


81 


4.06 


3.99 


81 


1.35 


3.21 


81 



296 



297 



Appendix H — Continued 



Network Characteristics Mean SD N 



Number of instrumental 
linkages 

Total personal network 
Relative network 
Nonrelative network 

Ratio of ties with material 
linkages to total ties 
(percentage) 

Total personal network 
Relative network 
Nonrelative network 

Ratio of reciprocal links to 
total links (percentage) 

Total personal network 
Relative network 
Nonrelative network 

Ratio of dependent links to 
total links (percentage) 

Total personal network 
Relative network 
Nonrelative network 

Ratio of instrumental links 
to total links (percentage) 

Total personal network 
Relative network 
Nonrelative network 

Ratio of perceived equivalent 
ties to total ties 
(percentage) 

Total personal network 
Relative network 
Nonrelative network 



.83 


1.53 


81 


.77 


1.42 


81 


.22 


1.34 


81 



80.08% 


24.78 


80 


87.41% 


19.65 


78 


62.45% 


44.28 


63 



52.28% 


29.68 


80 


56.54% 


28.61 


78 


50.01% 


45.03 


51 



38.45% 


31.24 


80 


33.68% 


31.24 


78 


46.38% 


45.38 


51 



8.22% 


16.13 


80 


9.78% 


18.12 


78 


13.36% 


77.97 


51 



73.01% 


59.54 


79 


67.49% 


39.24 


77 


68.81% 


45.14 


49 



298 



Appendix H— Continued 



Network Characteristics Mean SD N 



Mean emotional bondedness 



Total personal network 32.10 3.23 80 

Relative network 31.31 4.13 78 

Nonrelative network 33.09 3.14 63 



APPENDIX I 
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>i<0 

rH 4-> 
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C CD 

< e 



I 



CD 

rH 

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co 

CD 
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C f0 
CD CD 

£ K 



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C (0 
CD CD 

S a: 



as x: 
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x: K 



rH x: 

(0 4J 
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C c0 
CD CD 

a e 



rH 

CO JC 
O P 

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CO (0 
>i CD 

x: k 



to 
o 

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4-) 

to 

-.4 
14 
CD 
P 
CJ 
(0 

i4 

(0 
X 
CJ 

-M 

w 

o 

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(D 

z 



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00 CO 00 
in 00 rH 

• • • 
ro rH CN 



CN CN in 
VO O CN 



cn 



COCOH 
CN CN rH 

• • • 
VO 00 00 



cm vo o 

VO ^ O 

• • • 

VO 00 00 



rH O O 

cn r-\ r» 

• • • 

oo m r~ 

in rH rH 



rH 00 VO 
rH rH <Tl 



CN 



in 

CN 



309 

r-i rH r-\ 
00 00 00 



in vo in 
oo ro in 

• • • 
rH rH CN 



O CN CN 

in o oo 



r- ^ vo 
r- r~ ^r 



o cn cn 

VO CN rH 

• • • 

CN CN 



■** vo ■* 
cm r^ o 



r- ^r vo 
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in rH ro 

OHt 



rH CO rH 



O O «• 

OfOf 



ro rH o 

CN 00 CM 



H VOM 1 



ro »* co 

** CM 00 

• • • 

rH VO «tf 



CM •** O 

r- CN CM 

• • • 

o cm xr 

CN 



CM 
VO 



in 



oo 

CM 



CO 



oo ro in 
^ vo oo 

• • • 

^* CO ^* 
CM rH O 
CO CN VO 



r~ ro r« 

r~ rH O 

• • • 

ro oo r- 
ro rH o 

T* CN VO 



00 ^" 00 

cn o r~ 

• • • 

cn in m 
r- r- rH 

CM Ttf rH 



o oo o 

r-> P^ rH 

• • • 

ro «* in 

** VO CN 



in cm r- 

■* vo ** 

• • • 
VO VO «* 



«sr r~ oo 
in cm in 

• • • 

VO VO "* 



VO CN rH 

r~ oo ** 

• • • 

vo o vo 

CN 



rH VO rH 
O O O 

• • • 

CN CN 



CN 



C 



(0 





CD 


u 


CD 




<D 




CD 




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4-J 


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fC 


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CD -P 




> CO 


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> «0 




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•H rH 




•W rH 




•H rH 




■H r-\ 




rH 4-1 CD 


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rH 4J CD 




rH 4-1 CD 




rH P CD 




to as u 


4J 


CO CO U 




aS «S u 




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4J rH C 


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4J rH C 




4JH C 




O CD O 


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O CD O 


4J 


O CD O 


<D 


O CD O 




Eh « Z 




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CD 


Eh OS Z 


CD 




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to 




u 




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nj x; 




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W (0 




>1 CD 




x: eg 




A 




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CO 


P .H 


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c m 


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CD CD 


as 


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D 




O 1 




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x; k 




Ph 



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CD 

D 
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a> 
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(0 
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fd 

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p 

CD 
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O 00 iH 


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oo r- vo 


r* 


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co f- m 



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r— o o 



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in r-~ r~ 



oo ^j* oo 



conn 
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in co o 
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H cm co 



co 

CQ 
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c 

CD 

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c 
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H -P 
(0 <0 
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O CD 
EH « 



CD 
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4J 
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CD 
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2 



CN 



CN 



r~- cn in 


r- 


cm o co 


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• • • 


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CN CM ^f 





vo o r» 


CO 


r^nm 


CO 


• • • 


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co in en 


in 


iH 


CO 



in 



CO 



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CM 



CN 



CM 



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c 
o 

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c 
cr> 

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co 

o 
j-) 

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CQ 
CD 
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CD 

c 

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CQ 



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X! 

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o 



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O CO ^ 



O O O 
CM CN CM 



O O CM 
O «* T 



"3" ^ CO 



r- co o 
o o CM 



CM CM i-l 
O O CM 



r- oo o 

O O CM 



r- cm o 

O O i-l 



VO CM CO 
O O .H 



CD 

p 

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o 
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in 

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o 
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CO 

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c 



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O <D 
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p 

fd 
rH 
CD 
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CM CM rH 
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O "tf o 
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r~ in co 
o o o 



p 
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CD 
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H 4J 

CO CO 
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(0 4-> 




4-» rH 




C fd 




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S D3 


Gy 


rH 




fd x 




O -P 




•h rH 




CO fd 




>hCU 




x a: 




cu 




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CO 


4-> rH 


0> 


c <d 


u 


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rd 


a a: 


D 




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W 


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C 


O 4J 


(0 


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CD 


CO rd 


a 


>i<U 




XI CG 




Pi 




rHXi 


ca 


CO 4J 


cu 


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c <d 


as 


CU CU 


a 


a tc 


D 1 




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rH 


M-l 


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c 
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rH 

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CO 
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l-l 
CU 
4-> 
U 

in 

(d 
x 
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u 

o 

4-> 
CU 
2 



O CO r-H 


o\ r~ cn 


o oo ro 


o co ro 


oo r^ m 


r~ r-» vo 


co r-~ vo 


cor- vo 


^o^o 


CO 00 rH 


* 
o cn ro 


cn o in 


cn r- in 


VO O O 


cmoo 


cn in o 


• • • 


• • • 


• • • 


• • • 


rH rO CN 




CN ** 


r-\ 



* 








CO rH VO 


in ro ro 


COOh 


co o m 


in r~ cn 


CN CN CN 


oinn 


o m r~ 


• • • 


• • • 


• • • 


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in ro rH 









ro ro cn 


cn vo cn 


O O T 


rH -^ 00 


o o vo 


ro f-t iH 


CN CJ\ rH 


ro in cn 


• • • 


• • • 


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CN cn m 



cn ro CN 

O O VO 



in cn co 
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fd 

4-1 

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CU 

e 
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c 



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cvh 

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CU 

> 

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fd ro u 
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eh « z 



CN VO <T\ 

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CN CN r-» 

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ro •t r» 



r-» cn •** 

CN O CN 

• • • 
<J\ 00 



CN CM rH 

ro in cn 

• • • 

CN cn in 



rH o en 
in co cn 



ro 



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00 «J< T]< 


VO "3" *» 


O VO O 


rH rH CN 


O O O 


CN O CN 


CN CN <T> 



CN r-i 



cn 



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c c 
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u 



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4-> 
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cr 
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cn 
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ro rrj u 

4-> rH G 
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Eh ft 2 



U 

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Cn 

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fd 
cu 
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CO 

c 
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CO (0 
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I rH £ 




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CO (0 




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x; aa 




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CU 


c ra 


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cu cu 


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cr 




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(l) 


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ft 




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cu 


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C fO 


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cu cu 


3 


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W 






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4-1 


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o 

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p 

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p 
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03 
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a: 

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co r- vo 



* * 

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o r~ co 
« • • 



00 VO o 

moo 



CN 



CM CO LO 

rH in ro 



IT) CO VO 
rH VO CO 



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o vo o 
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o 

C 
cu 

D 
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P 

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c 



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03 
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m 


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Ch 


04 




Et4 








* 


■K 
* 


03 


a 



APPENDIX J 
VARIABLE EFFECTS ON THE 
PROCESS OF ACLF ENTRY 



4-1 




O 




-P 




3 




O 




4-4 




o 




co 




CD 




u 




u 




a 




o 




CO .* 




u 


rH 


O 


(0 


S 


e 


4J 


u 


(1) 


o 


C 


4H 




C ^H 


•H 


(TJ 




u 


• 


o 


CO 


4-1 


> 






T3 


-H 


C 


(0 


(0 


E 




u 


CD 


o 


M 


4-1 


D 




CO 


4-1 


(fl 


O 


CD 




e 


CO 




>0 


>i 


13 


-U 


O 


■H 




> 


cn-H 


o 


4-> 


rH 


o 




CD 


0) 


C 


jC 


c 


-P 


o 




u 


c 




o 


>! 




XI 


CO 




4-) 


■k 


U 


cn 


<D 


c 


4-1 


•H 


14-1 


rH 


CU 


CD 




XI 


0) 


<0 


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rH 


X! 




<TS 


CD 


•H 


o 


M 


(0 


<0 iH 


> 


a 



I 

0) 
H 
X 

to 

Eh 



u 
O 

4J 
CU 

2 



O 
O 
Cn 



0) 
>~ 

•H 00 
4J CO 

(0 
rH II 

CU 

U Z 

o 

2 



CU — 

>-* 

•h r- 

(0 II 

i-t 

CD Z 

05 — 



e~ 

•H 1> 

ii 

rH 

nj Z 

4J — 

o 

Eh 



a 



en 
o 



a 

CO 



CN 

o 



en 
o 



a 

CO 



cn 
o 



ro 



O V© VD CTl CN 00 CTl 
O CM rH rH Cn rH CTl 



I— IT) I— rH CO O CO 
rH CN CN rH CM rH CO 



rH r~ CTl CO CO CTl 
CN O 00 rH rH rH 



rH I 



CN 
O 



CN CN CO CTl CO rH *t 

(Jl IO O O rl if CO 



vo r> o ^ ro h cn 



rH I I 



rH 
O 



CN 
O 



CTl CTl VO IO IT) 00 CTl 
CTl VO O rH rH rH 00 



■K 
rH O 00 «* CN VO CN 

r- rH r~ ro cn oo oo 



CTl 



cn r-» co o ^r 
m en co rH cn 



ro 



CO <N CN CTl CO 
CTl VD O O rH 



* 
CTl 00 O ^ 
CN CO CO rH 
• • • • 
rH I I 



CM 



ro 



vo m m m in 

CTl VO O rH rH 



* 

* * 

* * 

*» r~ m ■<* o 

CTl CO CTl CO CN 



rH I I 















co 
















CO 














CO 
















CO 














CU 
















CU 














c 




r 












c 














T> 


= 


CU 












T3 














CU 


CU 


> 












CU 














■o 


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X! 














c 


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4J 












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4-> 


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CU 












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CO 




u 










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X 










CO 


1H 


3 










CU 


CD X 


D 










CU 


CU 


CO 










cc 


O 


CO 










C Xi 


(0 










TD 


4-> 


s 


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4-> 


CU 










0) 


O 


| 


1 










CU 


o 


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1 


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4-> 


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4-1 










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nj 


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j«: 


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1-1 










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4-> 


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a, a. 










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CU 


£ 


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c 


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CO 


X 


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4-1 


a> o 


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CU 


CO 


X 


o 


4-> 


cn 


c 


CO 


w 


CU 


m 


CU 


•H 


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u 


w 


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(0 


CU 


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c 


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co co 


Cn 


CO « 


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CU 












a 


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Q 













314 



315 



0) 

> ~ 

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■P CO 

r-l II 

01 

u Z 
c — 

o 



O 

01 

2 



(0 
O 
O 

Cm 



M 
(T3 

u r- 
Pn 
ll 

rH 

4J ^ 

O 

Eh 



I 
l"3 

0> 
rH 
X! 

<T3 



Q 

to 



en 
O 







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Q 


r-l 00 




W 


• • 


oj ^ 




r-i 


> "* 






•h r» 






4J 






(C II 






■H 


-P 


r-i r- 


0) 2 


•l-t 


ro *r 


« «- 


D^ 


• • 




O 


■H 




J 


1 



Q 

CO 



Cn 
O 



01 

u 
a 
w 

A3 

s 
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4J 



O 

cu 
c 
c 
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in r* 
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vo r- 



■ 

c 0) 
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XI 3 

CO 
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1 I 
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O O 
O O 
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ChCh 

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m 
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a, 

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cu 

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c 
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0) 
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CO 

a; 
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cr> 
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CD 
XI 



a; 
x: 

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o 

M-l 



CU 

o 
c 



01 

a) m-i 

M M-l 

nj -h 

w 
0> a> 



>1 

•H 

u 
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CU 
14-1 

o 

CO 
CU 

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a 

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CU 

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x; 
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X) 

CO 
0) 
TD 

D 

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X! 

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t-l 

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0) 

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4-1 

o 

CO 
■»-> 

c 
cu 

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CM 
01 
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>1 

■W 

o 
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u 
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CU 

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• V|_| 

>tO 
Xi 

■rH CU 

U U 

O 3 

U CO 

CXnj 
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CU 
V-l 



•h a> 

Di > 

O -H 



CU 

> 

u 

CU 
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X) 

D 
CO 

CU 

x: 

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x: 
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r-l 
XI 



x: 
cu 



T3 
01 

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U O 
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cu a> 

4J 



4-> 
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0) 
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(T5 



CU 
Cn 
l-( 

CU 

e 

CU 

CO 
4-1 
C 
CU 
•H 
O 

CO >1 C -rH 

O "+-( 

H M-l 

(0 01 

(0 O 

0) U 
U 

CU XT' 0> 

ot o) x; 

CO U 4J 



CU 
4J 

ca 
cu 



x; 



316 



Table J-2. Variable effects on the log odds of formal 
versus informal referral to an ACLF by 
connectivity measure and focal network 



*p < .10 
**p < .05 











Focal Network 








Total 
(N = 


Primary 
= 77) 


Relative 
(N = 74) 


Nonrelative 
(N = 46) 


Connectivity 
Measure 


Log it 




SD 


Log it 


SD 


Log it 


SD 


Density 


-.01 




.01 


.01 


.02 


.00 


.01 


Race 


.87 




.75 


.59 


.82 


.16 


.94 


SES 


.86 




.70 


1.00 


.74 


1.63* 


.87 


Sex 


-.83 




.61 


-.49 


.57 


-.58 


.76 


Degree 


-.13 




.11 


-.24 


.15 


-.18 


.18 


Race 


.95 




.78 


1.21 


.87 


.51 


.96 


SES 


.91 




.70 


.79 


.76 


1.79** 


.91 


Sex 


-.66 




.57 


-.42 


.58 


-.61 


.75 



317 



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c 
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CU 
Vj 

en 
cu 



APPENDIX K 
VARIABLE EFFECTS ON 
RETURNING HOME AND TIE DURATION 



Table K-l. 



Variable effects on staying in an institution 
by connectivity measure and focal network 







Focal 


Network 






Total Primary 
(N = 70) 


Relat 
(N = 


:ive 
69) 


Connectivity 
Measure 


Logit 


SD 


Logit 


SD 


Density, Time 1 


.03 


.03 


.02 


.04 


Sex 


-.06 


1.17 


-.34 


.98 


SES 


3.66** 


1.86 


2.19 


1.37 


Race 


-4.39** 


1.90 


-2.89* 


1.52 


Physical health, 
Time 2 


2.48** 


1.14 


2.49** 


1.10 


Network bondedness, 
Time 1 


.37** 


.18 


.15 


.11 


Closest other 

intensity, Time 1 


.04 


.17 


.14 


.18 


Reciprocity — 

"objective," Time la 


1.19 


1.89 


.78 


1.84 


Reciprocity — 

"subjective," Time 1 


.07 


1.27 


-1.07 


1.29 


Degree, Time 1 


-.14 


.14 


-.13 


.13 


Sex 


-1.10 


1.04 


-.70 


.95 


SES 


3.02* 


1.63 


2.07 


1.39 


Race 


3.61** 


1.60 


-2.52* 


1.43 


Physical health, 
Time 2 


2.36** 


1.08 


2.47** 


1.09 



322 



Table K-l— Continued 



323 



Focal Network 



Total Primary 
(N = 70) 



Relative 
(N = 67) 



Connectivity 
Measure 



Logit 



SD 



Logit 



SD 



Network bondedness, 
Time 1 

Closest other 

intensity, Time 1 

Reciprocity — 

"objective," Time 1 

Reciprocity — 

"subjective, Time 1 



.34** .16 



-.01 



.95 



-.16 



.18 



1.74 



1.20 



.15 



.12 



1.12 



-.80 



.11 



.18 



1.85 



1.29 



*p < .10. 

**p < .05. 

a 
While the table includes both measures of reciprocity, 
they were regressed on returning home separately. The 
reported coefficients of the remaining variables are 
from the regressions with the objective measure of 
reciprocity. 



324 



TO 
O 
O 
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T> 
C 
TO 

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x> 

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BIOGRAPHICAL SKETCH 

Mary J. Bear was born on March 24, 1955, in Milwaukee, 
Wisconsin. Mary married Roger Bear in 1979. In 1981, their 
son, David, was born and the birth of their daughter, 
Denise, was in 1985. Mary graduated Magna Cum Laude with 
the Bachelor of Science in Nursing degree from Vanderbilt 
University in 1976. In 1978, a Master of Science degree in 
nursing with a dual focus in community health and aging was 
earned from the University of Colorado. Her doctoral study 
in medical sociology and the sociology of aging resulted in 
earning a Ph.D. from the University of Florida in 1986. 
Currently, Mary is working part-time as a visiting 
assistant professor in the University of Florida's graduate 
community health nursing program. Her research interests 
are in the effects of social networks on the process of 
institutionalizing the elderly and the consequences of 
institutionalization on these networks. 



347 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, as 
a dissertation for the degree of Doctor of Philosophy. 




Gordon F. Streib, Chairman 
Graduate Research Professor 
of Sociology 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, as 
a dissertation for the degree of Doctor of Philosophy. 



f^Ut-^ju^J/ V^S Usi 




Leonard Beeghl< 

Associate Professor bf Sociology 

I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, as 
a dissertation for the degree of Doctor of Philosophy. 



f„.aQ..jiQv 



Lee Crandall 

Associate Professor of Sociology 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, as 
a dissertation for the degree of Doctor of Philosophy. 



Michael L. Radelet 

Associate Professor of Sociology 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, as 
a dissertation for the degree of Doctor of Philosophy. 




U^u£<^ iLi^M.** /— 



Pamela Richards 

Associate Professor of Sociology 



I certify that I have read this study and that in my 
opinion it conforms to acceptable standards of scholarly 
presentation and is fully adequate, in scope and quality, as 
a dissertation for the degree of Doctor of Philosophy. 




Otto Von Mering 
Professor of Anthropology 

This dissertation was submitted to the Graduate Faculty of 
the Department of Sociology in the College of Liberal Arts 
and Sciences and to the Graduate School and was accepted as 
partial fulfillment of the requirements for the degree of 
Doctor of Philosophy. 

December 1986 



Dean, Graduate School